Ongoing Management

Re-evaluate pain and function (assess analgesia and activity) periodically using standardized pain scales (e.g., verbal or numeric rating or visual analogue scales) to determine the need for continued pain medication
Assess current mood
Monitor patients for adverse effects and adherence
Consider incorrect pain diagnosis as a possible reason for non-response to medication
Follow strategies for exiting treatment when appropriate

Continue to monitor pain patients for substance abuse and inappropriate use throughout treatment

Stratify risk by using a risk assessment tool to determine level of monitoring needed (assign the patient to a low, medium, or high risk group for substance abuse disorders or noncompliant opioid use)
Monitor pain patients over time for other possible signs of medication abuse including non-compliance with medication regimens or drug-seeking or other aberrent behaviors using an assessment tool such as the PDUQ, COMM or similar.
Differentiate drug-seeking behaviors due to substance dependence or addiction from drug-seeking behaviors or misuse (overuse) due to under-treated pain
Recognize behaviors due to psychiatric problems or drug misuse for "chemical coping"
Regularly continue to screen for addiction, abuse, and chemical coping using a tool appropriate for chronic pain patients
Talk with significant others and obtain other collateral information
Ask about proper use of medication at each appointment and adjust medication if pain is under-treated
Consider implementing random urine drug testing in your pain practice
Select appropriate drugs for which to screen in urine drug tests
Recognize pseudoaddiction and opioid induced hyperalgesia as well as anxiety from therapeutic dependence and discern from addictive drug seeking

Address abuse of prescribed pain medications if it develops by tightening treatment structure and making appropriate referrals

Communicate effectively with patient about problematic medication use
Document abuse in the patient's medical record, including type, quantity, and duration of substances used
Prescribe pain medications in shorter time intervals and require more follow-up appointments
Require regular pill counts and limit medication refills
Increase other monitoring
Revise treatment agreements in accordance with tightened structure
If opioids must be discontinued, taper or detox humanely or refer for this purpose
Refer to a specialist if addiction is detected

Co-manage patients with specialists and other healthcare providers when appropriate

Identify patients requiring co-management with a specialist
Determine which type of specialist is appropriate, considering both addiction, pain, and other specialists
Distinguish between cases requiring a simple initial consultation versus ongoing co-management
Obtain legal permission to share patient information with all parties involved including addiction and pain specialists, other healthcare providers, family members, and friends
Establish an agreement between primary care, specialist healthcare providers, and other members of the treatment team that describes the care that each clinician will provide and includes a communication protocol and schedule of visits
Become familiar with any addiction treatment plans
Continually share information as appropriate with other healthcare providers throughout the patient's treatment

Case 1: Chris Chronic Pain - 29 YOBM

Chief Complaint: Chronic pelvic pain from past crushing injury
Narrative: Chris has been in treatment with you for 2 years and reports increased pain recently. It has been over a year since his last appointment.
Opioid Issue: Increasing pain possibly from opioid induced hyperalgesia; time lag since last appointment
Relevant Past Medical, Psychosocial, Family History: History of crushed pelvis in car accident at age 18
Objectives Covered: A

Case 2: Bob Backache - 52YOWM

Chief Complaint: Flare up of chronic back problem
Narrative: Bob is a long-term back pain patient (20+ years) who calls sporadically and asks for a refill. He reports that 4 back injuries have exacerbated the problem and thus he has called for refills more frequently as of late.
Opioid Issue: Increasingly frequent requests for refills
Relevant Past Medical, Psychosocial, Family History: Longstanding back pain started with injury while moving furniture over 20 years ago
Objectives Covered: B

Case 3: Tina TMJ - 27 YOBF

Chief Complaint: Lost her prescription for a refill on pain medication for chronic TMJ pain
Narrative: Tina says that a surgical procedure to relieve temporomandibular joint (TMJ) pain instead left her with constant jaw pain. She uses a fentanyl patch. During the interview she admitted that she started using 2 patches simultaneously, when the one patch you prescribed was not working. Then she found that she liked the euphoric effect and started wearing 2 patches all the time. Now she has pain if she does not use 2 patches. She obtained the second patch by seeing a second doctor.
Opioid Issue: Misuse/possible substance abuse
Relevant Past Medical, Psychosocial, Family History: TMJ problems since college; surgical treatment for TMJ problems 5 years ago was not effective
Objectives Covered: C, D

Core Courses: Initial Assessment • Initial Prescribing • Ongoing Management • Avoiding Diversion

Standardized Patients: Pain and Addiction Standardized Patient Example 1