Mount Carmel Health Partners Clinical Guidelines Chronic Pain Management | Page 4

Non-Pharmacologic Treatment
• Behavioral medicine: biofeedback, relaxation
therapy, psychotherapy
• Aerobic exercise
• Acupuncture
• Chiropractic
• Interventional approaches: nerve blocks, trigger point
injections, epidural steroid injections
• Ultrasonic stimulation
• Electrical neuromodulation: TENS
• Heat/cold application
• Physical and occupational therapy
• Surgical interventions
Prescription Drug Misuse
Opioid analgesics, benzodiazepines, other sedatives and tranquilizers, and stimulants have important medica l uses, but they also
stimulate the reward center of the brain. In susceptible individuals, this can lead to misuse, substance use disorders/addiction, and other
serious consequences. It has led to the development of an illicit market for these medications. Because of their potential for misuse,
addiction, and illicit diversion and sale, opioid analgesics, stimulants, and benzodiazepines and other sedatives/hypnotics are regulated,
restricting whether and how they can be prescribed. In the U.S., these drugs are referred to as "controlled substances" and subject to
Federal regulations.
Misuse is any use of a prescription medication that is outside of the manner and intent for which it was prescribed. This includes overuse,
use to get high, diversion (sharing or selling to others), having multiple prescribers or non-prescribed sources of the medication, and
concurrent use of alcohol, illicit substances, or non-prescribed controlled medications. Misuse is a necessary but insufficient criterion for a
substance use disorder.
Risk Factors
Patient factors associated with increased risk for opioid analgesic misuse when prescribed the medication for chronic pain include:
• Substance use disorder (most consistently identified), including tobacco use disorder
• Family history of a substance use disorder
• Mental health disorder, including depression or posttraumatic stress disorder
• History of legal problems or incarceration
• White race (compared with black race) despite studies that have identified greater clinician concern and closer monitoring for black
patients
• Age less than 40 to 45 years old, in most studies
Studies are most robust for misuse, but these are also generally considered to be risk factors for developing opioid use disorder and for
overdose.
Prevention
Optimize alternative treatments. The first principle in prevention is to reduce a patient’s and the clinician’s reliance on controlled
substances. Clinical indications for prescribing controlled substances, such as pain, anxiety, and attention deficit hyperactivity disorder,
each have evidenced-based treatment modalities that can complement or even replace use of controlled substances. These include
non-pharmacologic treatment with self-management strategies, behavioral treatments, physical therapy, as well as non-controlled
pharmacotherapy.
Monitoring patients who are prescribed a controlled substance should include regular follow-up, drug testing, pill counts, and use of
prescription monitoring programs or other information sources about patients who receive these medications from multiple prescribers.
Monitoring should include documentation of benefits and harms of treatment, including assessment of functional status to assure that
function is stable or improving on the current regimen, and evaluation for concerning behaviors that may indicate misuse or a substance
use disorder.
World Health Organization (WHO) Analgesic Ladder
PAIN
Non-Opioid
acetaminophen, aspirin,
NSAID, (paracetamol)
Opioid
codeine, tramadol, etc. Opioid
morphine, fentanyl, etc.
± adjuvant ± non-opioid
± adjuvant ± non-opioid
± adjuvant
MILD PAIN MILD TO MODERATE PAIN MODERATE TO SEVERE PAIN
Chronic Non-Cancer Pain Management - 4