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| Guideline for Disease Management in Correctional Settings: Chronic Noncancer Pain Management |
| By NCCHC Guidelines |
| Published: 07/22/2013 |
Introduction
Although clinical guidelines are important decision support for evidence-based practice, to leverage the potential of guidelines to improve patient outcomes and resource use, NCCHC recommends that health care delivery systems also have components including primary care teams, other decision support at the point of care (such as reminders), disease registries, and patient self-management support. These components have been shown to improve outcomes for patients with chronic conditions. In addition, we recommend establishment of a strategic quality management program that supports ongoing evaluation and improvement activities focused on a set of measures that emphasize outcomes as well as process and practice. For information on the chronic care model, model for improvement, and outcome measures see the resources listed on page 3. Chronic Noncancer Pain Management in Corrections The International Association for the Study of Pain defines chronic noncancer pain (CNCP) as ‘‘pain that persists beyond normal tissue healing time, which is assumed to be 3 months. It should be of sufficient intensity to adversely affect a patient’s well-being, level of function, and quality of life.” CNCP is not managed the same as cancer pain or pain at the end of life. Palliative care requires a separate guideline. Management of CNCP poses an enormous challenge to correctional health professionals. CNCP is a major source of frustration for patients and clinicians alike. An increasing number of patients are reporting CNCP and growing number enter correctional facilities with prescriptions for opioids. Yet, opioids (e.g., oxycodone, morphine, hydrocodone) are potentially problematic. Correctional populations are at high risk for opioid dependence and/or misuse of these drugs. Risk factors include substance abuse, psychiatric morbidity, and prior history of sale or misuse of drugs. Treatment of CNCP in corrections is further hindered by limited access to pain specialists and/or nonpharmacological treatments such as physical therapy, massage, or cognitive behavioral therapy that are available outside of corrections. Last, continuity of opioid treatment postrelease is challenging to arrange because few community physicians are willing to prescribe it for CNCP to persons recently released from a correctional facility. The general approach to CNCP management in corrections includes the following:
Management of CNCP begins with a thorough history, physical examination, review of previous records, and selected, indicated testing. These are critical to an accurate diagnosis and the development of an optimal treatment plan. Key elements of the history include how and when the pain developed, its character, its intensity, factors that relieve or aggravate the pain, and the existence of other symptoms that point toward an etiology. The history should also include a psychosocial assessment for mental health comorbidity (including evaluation and treatment of depression) and assessment of past and current substance abuse. Extensive imaging (e.g., CT scans, MRIs) and other testing in pursuit of a cause should be avoided in the absence of red flags (fever, weight loss, etc.). Current theories regarding CNCP suggest a complex intertwining of pain signals to the brain from somatic and emotional sources. Most often no clear etiology can be established. However, this does not mean that the patient is malingering. Previous medical records including diagnostic tests, treatments, and procedures should be obtained. For new inmates, the clinician should check the prescription monitoring program registry that is available in most states. This can verify an alleged prescription and facilitate assessment of “doctor shopping,” a common practice among persons with opioid dependence. Functional status should be assessed and documented based on both on patient report and staff observations. This includes effects on activities of daily living such as getting out of bed or a chair, bathing, walking, and exercising. In the case of new inmates who have been receiving long-term opioids, pain and function should be assessed at baseline prior to tapering the drug and tracked over time to assess any change. Treatment Nonpharmacological. This begins with caring and compassion. Empathic listening can be therapeutic. Patient education begins with normalization of pain and distinguishing it from acute pain in terms of etiology, pathophysiology, and treatment. The key objectives of education are to engage the patient in setting small goals for improved function and in developing an alternative focus beyond pain using distraction. Functional goals are typically patient-specific: able to walk 100 yards without stopping or able to sit for 30 minutes at a time. Clinicians should reassure patients that pain may worsen at first when activity is increased but that this is not damaging. Consideration should be given to physical modalities (heat or cold treatments), therapeutic exercise (range of motion, stretching, graduated activity), appropriate ergonomics, and physical therapy. Effective psychological treatments include cognitive behavioral therapy, relaxation therapy, and guided imagery. Group education provided by trained professional can be helpful. Pain agreements can help to clarify patient responsibilities and expectations while also reassuring patients they will not be abandoned by the clinician. Pharmacological. Begin with aspirin, acetaminophen, or a nonsteroidal anti-inflammatory drug (NSAID), depending on patient comorbidity and contraindications. Doses of acetaminophen should generally not exceed 650 mg per individual dose or 2,600 mg per day. Response to NSAIDs differs between agents. If response to one class is inadequate, a drug from a different NSAID class should be prescribed. Proton pump inhibitors or high-dose histamine antagonists should be prescribed for those at risk for aspirin- or NSAID-induced gastropathy (age > 65, previous history, comorbidity, and use of other drugs such as aspirin or anticoagulants). Periodic laboratory monitoring should be done depending on patient age and comorbidity. If these agents fail to improve pain and function, adjunct medications should be considered. Noradrenergic antidepressants or selected anticonvulsants are reasonable second-line agents. Doses should be titrated and given an adequate trial (usually several weeks). If a partial response is achieved, a second agent may be added. If there is no response, the drug should be discontinued and a drug from another class prescribed. Pain specialty consultation should be obtained for severe pain and functional impairment that is not responding. Opioids should be considered only when (a) all alternatives have failed to improve pain and function; (b) there is objective evidence of disease; (c) there is evidence of significant impaired function; (d) the patient provides written, informed consent; and (e) strict monitoring of use of the drug is feasible. Some facilities require either specialty consultation or a multidisciplinary team meeting to review and/or consider starting opioids. If an opioid is started, it should be done so as a therapeutic trial with clear measures for success. If those goals are not met, the drug should be tapered and discontinued. Monitoring Dose adjustments for any medication should be made during patient visits following adequate therapeutic trials. Any drug that fails to show improvement in pain or function should be discontinued to avoid needless risks and polypharmacy. Patients should be seen more frequently during medication titration. Monitoring by history and/or laboratory testing as appropriate should be based on the 4 A’s: adverse effects (side effects), activity (improvement in function), analgesia (change in pain level), and aberrant behavior (no misuse of medication). Daily diaries that enable patients to track their functional progress can be helpful. However, daily tracking of pain is usually not helpful. Patient should be seen at regularly scheduled visits, and should be praised for any progress toward meeting small, mutually defined functional goals. Education CNCP is among the most challenging problems to treat. Clinicians should seek out every opportunity to improve their clinical skills through conferences, workshops, and webinars offering continuing medical education on management of CNCP. Similarly, correctional staff with training about CNCP can become valuable team members both in terms of information about pain-related behavior and function and in collaborating on the management plan. Disparaging or mocking comments can accentuate CNCP. Conversely, a few encouraging words can motivate inmates to engage in self-management. Quality Improvement Measures
RESOURCE Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (2010) SOURCE Washington State Agency Medical Directors' Group URL http://www.bt.cdc.gov/coca/pdf/OpioidGdline.pdf RESOURCE Sample Doctor-Patient Agreements for Chronic Opioid Use (from the Interagency Guideline, Appendix G) SOURCE Washington State Agency Medical Directors' Group URL http://www.bt.cdc.gov/coca/pdf/OpioidGdline.pdf RESOURCE Clinical Practice Guideline: Management of Opioid Therapy for Chronic Pain (May 2010) SOURCE Department of Veterans Affairs, Department of Defense URL http://www.healthquality.va.gov/COT_312_Full-er.pdf RESOURCE Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol 54 (2011) SOURCE Substance Abuse and Mental Health Services Administration URL http://www.ncbi.nlm.nih.gov/books/NBK92048 RESOURCE Chronic Care Model (1998) SOURCE Developed by Ed Wagner MD, MPH, MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and the Improving Chronic Illness Care program. Available from the Institute for Healthcare Improvement URL http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/Changes/ RESOURCE Model for Improvement (1997) SOURCE Associates in Process Improvement. Available from the Institute for Healthcare Improvement URL http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove RESOURCE Measures SOURCE Institute for Healthcare Improvement URL http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Measures RESOURCE HEDIS & Quality Measurement SOURCE National Committee for Quality Assurance URL http://www.ncqa.org/tabid/59/Default.aspx Reprinted from NCCHC Guideline: Chronic Noncancer Pain Management |
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