Tips for Managing Chronic Pain in High-Risk Patient Populations

According to a 2011 Institute of Medicine Report (https://www.nap.edu/catalog/13172/relieving-pain-in-america-a-blueprint-for-transforming-prevention-care), 116 million Americans seek treatment for chronic pain. Opioids are often prescribed, but abuse and misuse of those drugs has created a public health epidemic.

DeLeon noted that healthcare providers should consider four important areas prior to prescribing opioids for pain.

• Patient history and physical examination
• Assessment and a plan that justifies the use of opioid therapy because other therapies are unavailable or ineffective
• Informed opioid consent
• Patient opioid therapy agreement

A patient-prescriber agreement (https://www.painedu.org/Downloads/AdditionalMaterials/Agreement_for_Opioid_Maintenance_Therapy_for_Non-Cancer_and_Cancer_Pain.pdf) should be drafted and signed by one prescribing doctor and one designated pharmacy and should include the following.

• Discussion of risks and benefits of opioid therapy
• Methods to monitor patient adherence
• Discouragement of early refills
• Guidance for safeguarding medications
• List of behaviors that may lead to treatment discontinuation

Healthcare providers should also discuss realistic goals with the patient, such as:

• Pain reduction: 30% is considered clinically significant
• Improvement in select functional areas (e.g., ability to work full-time, play golf once a week, walk the dog daily)
• Improved mood.

When monitoring patient adherence and risk for dependence, “Do not lower your guard,” DeLeon cautioned. Follow-up should occur every two weeks for a maximum of three months, and providers should review electronic medical records and talk to the office staff about any early renewal requests, uncensored increase in the treatment dose, patient story-telling (e.g., “The pills went down the drain.”), and confrontational attitude with the staff.

Adverse events (AEs) should also be managed closely, including hyperalgesia, sleep disturbance, and respiratory depression, which is the most serious AE associated with opioids. Respiratory depression occurs when the initial dose is too high, therapy is titrated too rapidly, drug-drug interactions occur, or the opioid is combined with other drugs, such as benzodiazepines, herbals, and over-the-counter preparations that contain diphenhydramine.

“Opioid therapy continues to be a viable alternative for the treatment of chronic pain; however, it is no longer justified to use them as monotherapy,” DeLeon concluded. “Several checks and balances must be in place, including an exit strategy.”

Pain With Sickle Cell Disease

Broglio then discussed pain associated with sickle cell disease (SCD), which affects an estimated 100,000 Americans. Pain in patients with SCD can be acute, recurrent events (related to vaso-occlusive crises [VOCs], orbital compression syndrome, and osteomyelitis), chronic pain syndromes (avascular necrosis), and neuropathic pain, which is not well understood. Consequences of acute pain crises can include acute chest syndrome, multiorgan failure, sudden death, and hospital readmissions.

When a patient with SCD presents in the emergency department with pain, consider intranasal fentanyl if IV access is not available. If VOC is suspected, pain management should not be delayed while waiting for laboratory values, Broglio said. “Clinicians should respect patient report of severity of pain and should manage pain regardless of the [patient’s] gender.”

For chronic pain, “always consider multimodel therapy,” Broglio advised, including regional anesthesia, opioids, local anesthetics, acetaminophen, nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, alpha₂-agnoists (e.g., clonide, dexamedetomidine), anticonvulsants (e.g., gabapentin, pregabalin), N-methyl-D-aspartate receptor antagonists (e.g., ketamine), and adjuvant therapies (e.g., skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors [SNRIs], and tricyclic antidepressants [TCAs]).

Broglio highlighted that acute pain should be managed in a timely manner, patients should be educated to prevent VOCs, and pain should be managed via a comprehensive approach with multimodal analgesia.

Multimodal Therapies for Neuropathic Pain

Neuropathic pain develops as a result of lesions or disease affecting the somatosensory nervous system and is characterized by spontaneous ongoing or shooting pain and amplified pain responses after noxious or non-noxious stimuli, Grimmer explained. Neuropathic pain types include toxicity, metabolic disease, trauma, compression, autoimmune disorders, infection, and congenital disease.

This type of pain is difficult to manage because of barriers to good pain control and failure to identify the underlying pain mechanisms to appropriately prescribe treatment, Grimmer said.

According to the International Association for the Study of Pain guidelines, firstline treatment recommendations include gabapentin 1,200–3,600 mg (in three doses), pregabalin 300–600 mg (in two doses), SNRIs, and TCAs 25–150 mg (once daily or in two doses). The guideline recommends against the use of cannabinoids (weak evidence), valproate (weak evidence), levetiracetam (strong evidence), and mexiletine (strong evidence).

The National Comprehensive Cancer Network (NCCN) Adult Cancer Pain guidelines advise four goals of pain management: optimize analgesia, optimize activities of daily living, minimize AEs, and avoid aberrant drug taking. The NCCN principles of adjuvant analgesic use for neuropathic pain suggest antidepressants and anticonvulsants for firstline adjuvant therapy for cancer-related neuropathic pain.

Psychosocial support and screening should be included for all patients, Grimmer said. To improve pain management, other cognitive modalities should be considered, such as imagery/hypnosis, distraction and relaxation training, active coping training, cognitive behavioral training, and graded task assignments, goal setting, pacing, and prioritizing.

“It is crucial to evaluate and properly determine the source of a patient’s pain complaints to appropriately initiate pharmacotherapies,” she concluded. “It is not uncommon to require more than one adjuvant analgesic agent to adequately manage neuropathic pain complaints.”