Clinical Practice Update 207    

Jill Fenske, MD, Thomas Bishop, PsyD

Pain is the most common reason individuals seek health care, yet treatment is often incomplete and ineffective. The nation-wide opioid epidemic adds complexity in the management of pain.  Opioids carry substantial risk for harm, and are not recommended for the majority of patients.  With the widespread adoption of the CDC opioid-prescribing guidelines in 2016, rates of opioid prescriptions have decreased. Unfortunately, in some cases, the inflexible application of these guidelines have led to patient abandonment and poor outcomes. Prescribers need training, resources, and support to manage patients with chronic pain in a compassionate and safe manner, including those who are taking opioid medications.  There is also a need for better  access to non-opioid pain management services and treatment for opioid use disorder. Our health system developed an ambulatory pain management guideline intended to support clinicians in evaluating and managing patients with pain and in navigating the complex issues involved with the use of opioids.  We will review a biopsychosocial model for the assessment of chronic pain and present evidence-based treatment guidelines.  The central recommendation is the development of an individualized pain treatment plan that incorporates shared decision making, emphasizes interventions with the lowest risks and includes non-pharmacologic interventions as a necessary component.  We will review how an integrated team can partner with patients to increase function, quality of life, and safety in chronic pain treatment.  We will discuss dilemmas faced by prescribers in the management of chronic opioid therapy, and provide recommendations for addressing safety concerns in an empathic manner.