4. Discuss Treatment Options

Discuss Treatment Options and the Role (and limits) of Opioids

Setting functional goals for patients

As with any chronic disease, actual measures and documentation of these measures at baseline and follow-up is absolutely essential in guiding treatment decisions. Definition of treatment “success” may vary between patients and practitioners but using objective measures and sharing changes in these measures with patients may aid in informed decision-making on the part of patients as they discuss future treatment plans.

Once you have determined a diagnosis, agree upon a treatment plan that includes establishing functional goals for the patient, rather than one that is related to the severity of the pain itself. For example, encourage your patient to think about what activity they would like to engage in instead of “get my pain down to a level 3”. This should be done at least initially according to the new law but periodically thereafter, ideally at each visit.

Discuss Treatment Options for Chronic Pain

In assessing different treatment options for your patient’s pain, you should first explore non-opioid methods of controlling pain and improving function.

Refer to the flowchart from First Do No Harm entitled “An Approach to Managing Chronic Non-Terminal Pain” for a range of non-opioid treatment options.

Do no harm approach to managing chronic pain flowchart

For many diagnoses, there is more evidence of benefit of these therapies than for chronic opioid therapy.

Avoid polypharmacy in treatment plans, particularly when using opioids. Medications such as stimulants, benzodiazepines, mixed opioids (long- and short-acting) can be particularly dangerous, harmful or counterproductive and should be avoided. The new state law explicitly discourages this type of polypharmacy.

Though opioids are not widely considered to be a first-line agent in the management of chronic pain, they can play a role in a comprehensive chronic pain management plan. Individualized assessment, rather than absolute “rules” about personal practice patterns (e.g., “I never prescribe narcotics”) should guide treatment decisions. The appropriate combination of agents may include opioids and adjunctive modalities such as other analgesics, antidepressants, anti-epileptics, acupuncture, soft-tissue injections, massage, yoga, TENS unit, water aerobics, meditation, and other evidence-based treatments.

If You Do Decide on Opioids…

The Role of Opioids: Management not Treatment

In the end, it is important that you have a frank discussion with the patient regarding the palliative role of opioid pain management: patients need to be told about the difference between treating the underlying CAUSE of pain, and lessoning the, still underlying, pain through opioid pain management. Having a clear understanding of these differences can help patients better manage their expectations.

Always remember to never start a treatment that you are not prepared to stop. If the patient’s pain or functionality doesn’t improve on the opioid, let them know that it will be discontinued.

The Emergency Medical Rules Law mandates discussion with patients and documentation of risks of opioid therapy (including death) initially and periodically thereafter.

The 3 E’s for Opioid Treatment: Education, Expectations, and Explicit Instructions

When developing a treatment agreement with a patient, it is very important that the patient know what the medication is and isn’t for, what they can expect, and exactly how to take the medication. This involves the 3 E’s.

3 E's

Education:

  • What is chronic pain?
  • What is the risk of aberrancy?
  • What are the diagnoses?
  • Risks of treatment?

Expectations:

  • How much pain relief?
  • How much functional recovery? i.e. Is there increased physical activity?

Explicit instructions:

  • On Medication Use
  • Take as directed only
  • Report side-effects
  • No early refills

and that you will:

  • Monitor use
  • Adjust treatment as indicated based on goals, adherence to program and pain

Mr. Hawkins defaultClient Case: Mr. Hawkins

As with informed consent, these issues should be discussed with the patient to ensure understanding and agreement with the treatment. After discussing the risks and benefits of opioid therapy with Mr. Hawkins, you prescribe hydrocodone/acetaminophen 5/325 mg to be used only for pain that is uncontrolled by local heat, stretching, meloxicam and/or cyclobenzaprine. You advise him never to take the medication “first thing in the morning” before he has tried other modalities and further advise him to avoid routine use.

Knowledge Check

You set other expectations for him that you outline in a written agreement that you have for such purposes, including which of the following?

a. You are the only person who will be prescribing these types of medications b. Lost prescriptions will not be replaced c. You will regularly see and examine your patient and reassess his status d. All of the above