Chronic Pain Management

A comprehensive patient assessment should be conducted to gather information that may help inform clinical decisions and the treatment plan. The patient’s assessment should cover the following areas¹:

• Pain and Coping: Identify the origin, type, nature, severity, and location of the patient’s pain. Ask the patient about aggravating and alleviating factors. Understanding the patient’s previous history with treatment for this pain (including methods used and patient response) can also be useful to help make appropriate decisions and to understand the patient’s goals or expectations for pain relief.
• Function: Determine the effect of pain on patients’ daily life, sleep, mood, relationships, and other factors. Ask patients about their goals and expectations for function.
• Co-Occurring Conditions and Disorders: Providers should have already conducted a thorough assessment of the patient’s substance use disorders, mental health conditions, medical conditions, and cognitive impairments. Use the findings of these assessments as well as knowledge of the patient’s history to inform decisions about the treatment or management of pain.
• Physical Status: Perform a physical medical exam to help inform the pain diagnosis and treatment planning. This exam should include the patient’s sensory experiences, relevant musculoskeletal area, and other nonverbal or verbal pain behavior depending on position.
• Mental Status: Assess the patient’s mood and cognitive capacity (e.g., attention or memory). If there are signs or symptoms of suicidal ideation or behaviors, take appropriate actions as described in the section on Suicidality.
• Additional Information: Collect any other information that may be relevant to the treatment or management of the patient’s pain. This information may include findings and recommendations from other clinicians, cultural beliefs or concerns, and data from the State’s prescription drug monitoring program. Also, aim to identify potential barriers to the effective management of pain, such as financial or insurance barriers and lack of social supports.

Standardized instruments should be used to screen and assess the patient’s:

• Dimensions of pain (e.g., Brief Pain Inventory, McGill Pain Questionnaire);
• Function (e.g., Katz Index of Independence in Activities of Daily Living, Pain Disability Index [PDF—122 KB]);
• Coping (e.g., Chronic Pain Acceptance Questionnaire [PDF—9.8 KB]); and
• Pain-related fear or anxiety (e.g., Fear-Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia [PDF—119 KB], Pain Catastrophizing Scale [PDF—3.5 MB]).

These instruments have strengths and weaknesses, and a single instrument may not be appropriate for use with all patient populations.¹ Historically, providers have also assessed a patient’s pain level using tools such as a numeric rating scale or visual analog scale. However, the utility and validity of these tools has been questioned in relation to chronic pain.

Providers should keep in mind that assessment of pain levels can be complicated. For example, patients may not fully distinguish between pain and suffering, leading them to report higher levels of pain intensity overall.¹ Also, providers’ attitudes may inadvertently affect their assessment of a patient’s pain. Clinicians often believe patient’s pain to be lower than what the patient reports and are more likely to underestimate and undertreat pain and disability in women, older adults, minorities, low-income patients, and individuals with substance use disorders.¹ For the purposes of this Playbook, we recommend treatment approaches that focus on improving a patient’s pain-related functioning rather than pain level.

Providers should aim to take a comprehensive, integrated approach to the complex care and management of pain among individuals with opioid use disorder. They should assemble a multidisciplinary group of providers that can include professionals such as:

• Primary care providers,
• Addiction specialists,
• Pain clinicians,
• Nurses,
• Pharmacists,
• Behavioral health professionals, and
• Physical or occupational therapists.¹

Ideally, providers are colocated and can take a team-based approach within the same practice, organization, or health system to foster collaboration.¹ However, providers in small practices will likely need to seek and coordinate care with external providers in the community.

Strategies for pain management in patients receiving medication-assisted treatment (MAT) services should be specified as part of the treatment plan. Providers may want to recommend nonpharmacologic treatments, such as therapeutic exercise, physical therapy, cognitive-behavioral therapy, and complementary and alternative medicine.¹

If pharmacologic treatment is clinically indicated, it is best to use Nonopioid Treatments for Chronic Pain (PDF—1.53 MB). For example, the first course of treatment should be nonnarcotic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs.² Other drugs, such as serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, anticonvulsants, and topical analgesics, may have analgesic properties for certain conditions.¹

Additional considerations depend on which medication the patient is taking to treat his or her opioid use disorder. For example, providers may consider adjusting the dose and schedule of buprenorphine in patients with chronic pain.² The following resources offer guidance and recommendations for providing pain management in individuals with substance use disorders:

• National Practice Guideline Supplement—American Society of Addiction Medicine
• Treatment Improvement Protocol 54: Managing Chronic Pain in Adults with or in Recovery From Substance Use Disorders—Substance Abuse and Mental Health Services Administration

Individuals with chronic pain and opioid use disorders are also more likely to have co-occurring mental health disorders, for which providers should screen. These disorders may further complicate treatment of this patient population. For example, anxiety can contribute to overall suffering and harm a patient’s quality of life. Similarly, depression may interfere with treatment adherence or ongoing management of the patient’s condition.¹ If needed, the practice should tailor the treatment team and interventions to address co-occurring mental health conditions.

When patients are hospitalized or undergo procedures in other outpatient settings, it is important for patients and providers to understand the risks and implications of pain management among those taking medications to treat opioid use disorder. For example, patients taking naltrexone should not be prescribed opioids because, as an antagonist, it will block the effects of these drugs. If providers continue to increase the dose of opioids to overcome this blockade, patients may be at risk of respiratory arrest as naltrexone levels decrease over time.¹

Patients should always tell their MAT prescriber in advance if they will be having a procedure that may require pain medication.³ Then, members of the care team should engage the patient in a shared decision-making process to discuss pain management options for this procedure.³ The care team should then work to coordinate with the external providers performing the procedure to ensure that the patient’s needs are met and preferences are respected.

MAT prescribers may need to be proactive with the inpatient team around discharge planning for their patient. They should ensure considerations are made around pain management issues with full agonists after discharge or restarting buprenorphine before discharge if needed.

Providers should also prepare patients and their families to explain what medications they are taking and to advocate for their own preferences in emergency situations. Some patients will want to avoid opioid analgesics at all costs, while others may be concerned that undertreated pain may be a trigger for illicit opioid use or prescription opioid misuse.³ In these situations, education and patient engagement in decision making are key.