Abstract
In the United States, many visits to physician offices are for complaints of pain. Patients who have moderate to severe pain can be effectively treated with different modalities, including the use of opioids. Effective management requires that the physicians be open minded and thorough. Physicians should take a complete history and do a complete physical examination, including an osteopathic structural examination, to help develop a comprehensive treatment plan. This plan should include follow-up visits for continued assessment of the treatment plan. A continued reassessment of the treatment plan and the patient's response to the treatment has been shown to be most beneficial to the patient and the physician. Osteopathic physicians using the osteopathic medical model of treatment should identify psychosocial as well as somatic dysfunctions and appropriately treat patients for them. They should not avoid the use of opioids because of fear of patients' becoming addicted, but rather they should integrate the use of opioids in a multidisciplinary treatment plan. Opioids are potent drugs that require monitoring and dosing according to patient response.
More than 75 million Americans have serious pain annually,
1 with 50 million having chronic pain (most commonly headache, lower back pain, arthritis, and other joint pain
2), and 25 million, acute pain. Pain accounts for an estimated $61.2 billion dollars in lost productive time annually; 76.6% of that cost is attributed to poor health–related performance while at work.
3 Pain is identified as the third leading cause of sick days, and a 1996 survey showed at least $3 billion in wages for paid sick days in 1995 were due to pain.
4 Common pain complaints were found to account for 13% of the total workforce losing productive time within a 2-week period.
3 Adequate pain control is necessary to allow patients to have a meaningful and productive life. Opioid use for pain management allows successful restoration of this ability. Thus, this article looks at opioid use for effective pain control in patients with moderate to severe pain.
Opioids can be traced back 8000 years to a Sumerian ideogram of
hul gil, the “plant of joy.” Throughout history, opioids have been found useful in the treatment of a multiple of ailments. In the early 1900s, opioids became a controlled substance to be prescribed for medicinal reasons only; it could not be prescribed to addicts. Throughout the 20th century, control became tighter with the 1970 Federal Controlled Substance Act,
5 which increased the monitoring of opioids and other controlled substances and required registration of all prescribers. In certain contexts, this social move regulating medical practice and criminalizing the prescribing of these controlled substances created problems. These legal ramifications led to undertreatment of patients with pain, illegal opioid trafficking, and addiction.
With continued education of healthcare providers, modifications in healthcare policy, consistency in management, and assessment in patient care, the emphasis on opioids as a legal issue shifted to a focus on medical management approaches.
6
To understand and effectively treat patients in pain, physicians must do a comprehensive evaluation that includes history, severity of pain, quality of life, and physical examination. Physicians should obtain and record a comprehensive medical, surgical, and family history, as well as a history relative to prior pain treatment modalities and their effectiveness. Necessary documentation includes a complete list of current and past medications, including over-the-counter medications and supplements, as well as a history of alcohol, tobacco, and illicit drug consumptions. Physicians should also query patients to ascertain if they understand their dysfunction and their prognosis.
6
When patients are viewed as part of the treatment plan, they develop a greater understanding of their pain. They are able to better discriminate and characterize their pain, thus assisting physicians to better understand how the treatment plan is benefiting their patients. Patients should describe the pain in their words and use a diagram or illustration to designate the location. They should describe the onset, history, and pattern over time. Use of a visual analog scale (
Figure 1) allows documentation of the patient's pain at each visit for future comparisons. Patients should describe associated factors that relieve or exacerbate the pain.
6
Physicians must identify the impairment or identify how pain is adversely affecting various aspects of their patients' quality of life. Patients should evaluate their physical and psychosocial well-being. Patients should develop an understanding of how pain is adversely affecting their roles as an employee, spouse, parent, and human being. Physicians should take into account patients' spiritual/religious beliefs so they can be aware of how the disease process relates to patients' belief system. Physicians should help patients understand how their ailment can affect their financial status, for example, cost of medicines, cost of physician visits, and lost wages (singly or in combination).
5 These characteristics are strongly tied to the success of a program and give subjective measures by which physicians can document progress.
7
Physicians must establish the treatment goal for each patient with pain and know what the patient expects. It is important for physicians to relate realistic goals to their patients, thus offering opportunity for patient education on treatment and for improved chance of success, as well as increased patient compliance and ownership of their problem.
A physical examination evaluating all systems, active and passive range of motion, strength testing, neurologic testing, and structural and postural assessment should be included in the initial assessment.
8 Documenting objective findings allows comparison at follow-up visits to assess improvement or failure with the treatment plan. Applying the osteopathic model addresses the entire physical and spiritual being as a whole, allowing for the diagnosis of a somatic dysfunction.
9 Figure 2 outlines the paradigm of treatment of patients with pain.
When using opioids in the treatment of patients in pain, the treatment plan should be comprehensive, including:
Administration of opioids for pain control has been shown to be an effective way to improve pain control and quality of life. Narcotics are potent analgesics that have potential for adverse effects. The risk-to-benefit profile of these drugs should be evaluated by both the physician and the patient.
10
Many physicians are concerned about patients' becoming addicted with the use of opioids for pain management. It was found that physicians prescribing opioid therapy had a confidence level of 75% in patients with chronic cancer pain and no history of drug abuse and their confidence level dropped to 3% for patients with noncancer pain and drug abuse history. Only between 3.2% and 18.9% of patients with a prior history of addictive behavior become addicted, a prevalence rate that is approximate to that of the general population without a history of addiction.
11 Furthermore, for patients with no history of drug abuse for whom opioid medication was prescribed for pain, the prevalence of drug addiction drops to less than 1%.
12
It is well documented that clear differences exist between physical dependence, tolerance, and addiction (
Figure 3). Tolerance occurs when the body adapts to the daily dose of the drug such that the pharmacologic effect is reduced; consequently, more drug is required to achieve the desired therapeutic action. Physical dependence is a more significant adaptation such that withdrawal reactions would occur on decreasing the dose. Addiction is a behavioral response whereby a person, despite adverse consequences, acts on compulsion to obtain and consume a drug. Undertreatment for pain may lead to drug-seeking behaviors to self-medicate.
11,12
An understanding should be made between the patient and the physician that the patient's potent medication is for his or her use only and is to be taken as agreed on by the patient and the physician. Such an understanding should be written as contract or agreement signed by both parties (
Figure 4). It is essential that there be one prescribing physician and one pharmacy to avoid the potential for error or diversion, or both.
Initial therapy should be with the lowest effective dose possible to minimize pain and medication side effects and to maximize the quality of life. The only limiting factor to the dose of opioids is patient response. Therefore, it is necessary to titrate the dose levels.
Selection of the proper opioid (
Figure 5) is crucial. Opioid dosing and conversion are complex procedures, as indicated by three Web sites.
13-15 The greater the affinity of the opioid at the mu receptor, the greater the analgesic effect or potency.
10 Opioids have pharmacokinetic differences in their bioavailability, such as morphine, which is the standard, compared with fentanyl, which is 50 times the potency of morphine. The medication becomes converted in the liver and to a lesser degree in the kidneys into the active metabolites.
10 Scheduling dosing is more effective at pain control and improving quality of life.
16 Combining sustained-release and immediate-release dosage forms has been shown to be effective.
16 Having “rescue” or “breakthrough”' medication (ie, immediate-release), allows the patient in periods of aggravated pain to increase the dose in minor steps to stabilize the pain.
17
Follow-up visits and continued monitoring is crucial for success and proper management of pain. These visits ensure constant communication, patient coordination, patient support, and opportunities for education and proper adjustments to medication. Visits should be scheduled every 2 weeks for the first 2 to 4 months, then once a month.
6 Pain medication should be prescribed at each office visit, with the dosage adjusted as needed on patient reports of pain, use of rescue dosing, and quality of life. Education should consist of goal-setting and helping patients understand different measures in pain relief through reduction in pain, improvements in quality of life, and decreases in the need for rescue drugs.
18
Having a multidisciplinary team of healthcare professionals who coordinate their efforts has proven to be effective in the management of pain. Depending on the identified specific needs of the patient, the team approach could consist of physical therapy, occupational therapy, psychologic treatment, sclerotherapy, physiatrics, interventional anesthesia, or invasive procedures (singly or in combination).
8 The multidisciplinary approach has been shown to increase the pain reduction by 20% to 40%, and the effects are maintained up to 2 years.
7 Using osteopathic medicine skills during office visits can aid in pain reduction. Improving postural and mechanical alignments, fascial strains, and tissue texture changes through the use of OMT can be highly effective for pain management and the body's innate ability to heal, the very foundation of osteopathic medicine.
19
When the patient has improved significantly, it is vital that the opioid medication not be discontinued abruptly so as to avoid the patient's having withdrawal symptoms. The patient must be tapered off of the medication by decreasing the dose slowly, reducing the dose every 2 to 3 days.
11
Comprehensive history, assessment—including an osteopathic structural examination—management, and education assure the success in reducing patients' pain. These key elements decrease the already small risk of opioid abuse. Understanding the need for titration and opioid tolerance and the potential need to increase dosing over time is an important concept. With combined effort, frequent reassessment, and patient understanding, opioid abuse is significantly reduced and the ability to improve quality of life and pain reduction can be obtained. Understanding the difference between addiction (psychological and deviant behavioral condition) and physical dependence (pharmacokinetic property—more related to compensatory changes at the receptor level [number or affinity or both]) should improve physician comfort levels in prescribing opioid therapy.