Chronic Pain

Guidelines

These guidelines are intended to address uncertainties surrounding the use of opioids in the treatment of chronic pain. Includes specific information on dosages, when to start and when to stop prescribing opioids, screeners, practice management strategies, handouts and educational materials.

Interagency Guideline on Prescribing Opioids for Pain

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Recommendations and Reports / March 18, 2016 / 65(1);1–49

Group Health Cooperative. Patients on Chronic Opioid Therapy for Chronic Non-Cancer Pain: Safety Guideline

Screeners

Opioid Risk Tool

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Medicine. 2005. 6(6): 432-42.

Screener and Opioid Assessment for Patients with Pain (SOAPP)

Akbik, H, Butler, SF, Budman, SH, Fernandez, K, Katz, NP, Jamison, RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). Journal of Pain and Symptom Management. 2006. 32(3): 287-293.

This article presents data related to the SOAPP survey: a brief, self-administered screening instrument used to assess suitability of long-term opioid therapy for chronic pain patients.

Articles

Bawa, F. L. M., Mercer, S. W., Atherton, R. J., Clague, F., Keen, A., Scott, N. W., & Bond, C. M. (2015). Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis. Br J Gen Pract, 65(635), e387-e400.

Meta-analysis indicating the need for improvements in the study of connections between mindfulness based interventions and chronic pain outcomes.

Heit, HA. Addiction, Physical dependence and tolerance: Precise definitions to help clinicians evaluate and treat the patient with chronic pain. J Pain and Palliative Care Pharmacotherapy. March/April 2003.26:655-667.

This report explains definitions of addiction, physical dependence and tolerance and how they apply to clinical practice, as formulated by a special Committee on Pain and Addiction from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine.

Moyers, T. B., & Miller, W. R. (2013). Is low therapist empathy toxic?. Psychology of Addictive Behaviors, 27(3), 878.

Article detailing research on the value of accurate empathy in therapy outcomes.

Passik SD, Kirsh KL. The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse. Experimental and Clinical Psychopharmacology, 2008.Oct;16(5):400-4.

This article provides a review of pain management efforts and focuses on two key areas of potential interest. First, the emergence of prescreening tools for identifying appropriate candidates for opioid therapy are introduced and discussed, including the Opioid Risk Tool (ORT), the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Pain Assessment and Documentation Tool (PADT). Additionally, a novel concept of "in and out of the box" prescribing is presented, focusing on five areas of concern for judging whether one's prescribing patterns are matching peer prescribing patterns.

Gourlay, DL, Heit, HA, Almahrezi, A. universal precautions in pain medicine: a rational approach to the management of chronic pain. Pain Med. 2005; 6(2): 107-112.

This provides a unified 10-step approach to the assessment and management of patients suffering from chronic pain and a triage scheme of risk stratification was offered, making it possible to discern which patients whom primary care practitioners might confidently manage on their own, comanage with specialty support, or refer to specialty clinics. Universal Precautions is not simply about opioid prescribing, but about all medication treatments for chronic pain.

Books

Turk, Dennis C., and Robert J. Gatchel, eds. Psychological approaches to pain management: a practitioner's handbook. Guilford publications, 2013.

Designed for maximum clinical utility, this volume shows how to tailor psychological treatment programs to patients suffering from a wide range of pain problems. Conceptual and diagnostic issues are discussed, widely used clinical models reviewed, and a framework presented for integrating psychological treatment with medical and surgical interventions.

Baer, R. A. (Ed.). (2015). Mindfulness-based treatment approaches: Clinician's guide to evidence base and applications. Academic Press.

Discusses the conceptual foundation, implementation, and evidence base for the four best-researched mindfulness treatments: mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT).

Hunter, C. L. (2010). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention / Christopher L. Hunter. Washington: American Psychological Association.

Interwoven through each chapter are practical tips for success and traps to avoid. The book includes a rich array of reproducible assessment questions, patient handouts, and sample scripts. All of these help the clinician alter his or her assessment and intervention skills in a manner that leads to focused interactions that work well within the fast pace of primary care.

Pohl, M, Donahue, M. A Day Without Pain. Las Vegas, NV: Central Recovery Press. 2008.

Dr. Pohl is an addiction doc and uses lots of different treatment modalities, including acupuncture, hydrotherapy, music therapy, aromatherapy, oxygen therapy, hypnotherapy, yoga, meditation, exercise, nutrition, biofeedback, chiropractic, and an entire chapter devoted to cognitive behavioral therapy, which has been shown to lessen pain by changing the way a person thinks about pain. This book covers the characteristics of all chronic pain, regardless of the cause.

Dahl, J, Wilson, KG, Luciano, C, Hayes, SC. Acceptance and Commitment Therapy for Chronic Pain. Reno, Nevada: Contact Press. 2005.

This provides the rationale, evidence and protocol for using Acceptance and Commitment Therapy with patients with chronic pain, based on the authors’ experience in working with a large population of patients on disability in Sweden.
A follow up article by the authors from 2014: Vowles, Kevin E., et al. "Acceptance and commitment therapy for chronic pain: Evidence of mediation and clinically significant change following an abbreviated interdisciplinary program of rehabilitation." The Journal of Pain 15.1 (2014): 101-113.

Dahl, J, Lundgren, T. Living Beyond Your Pain: Using acceptance and commitment therapy to ease chronic pain. Oakland, CA: New Harbinger Press. 2006.

This is a step-by-step program that provides rationale and exercises to help patients live a vital and meaningful life, alongside their pain. This can be used by patients as a stand-alone product or by professionals to integrate into individual or group treatment.

On-Line Resources

American Academy of Pain Medicine

Excellent resource of information for providers, patients and advocates. Includes online CME presentations, FDA information and alerts, practice management information and more. Some information requires a free login and other requires a membership.

AAFP Management of Chronic Pain Series.

This CME podcast series is available to AAFP members only and addresses the challenges of managing patients with chronic non-malignant pain. In addition to reviewing the evidence-based recommendations about assessment and management, the series also offers strategies and tools to assist physicians in integrating these principles into practice.

Pain.EDU

This website contains free educational resources for improving chronic pain treatment. It contains free validated screening tools for monitoring risk of misuse of opioid treatments and downloadable treatment guides such as "Managing Chronic Pain with Opioids in Primary Care". This guide provides recommendations on assessment, treatment strategies, documentation, and ongoing monitoring. Sample forms of SOAPP and COMM assessment tools and scoring rubrics are included in the guide. Sponsored by pharmaceutical company.