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Managed Care
Reimbursement practices often favor more expensive pain measures by paying
for inpatient procedures but requiring the patient and family to pay for
outpatient procedures.7 Appropriate pain management may help patients
avoid hospitalization or invasive therapies.
Optimal Management
Optimal management of pain involves consideration of different treatment
modalities, such as a formal pain rehabilitation program, the use of
behavioral strategies, the use of noninvasive techniques, or the use of
medications, depending upon the physical and psychosocial impairment
related to the pain. Appropriate and regular documentation of the
patient’s assessment of pain should be included. Management of side
effects and appropriate use of nonpharmacologic treatments are also
recommended. Physicians should understand the procedures recommended for
special populations such as the elderly and patients with a history of
drug-addiction or a coexisting psychiatric disorder. Patient
quality-of-life and site quality of pain management should be monitored.1
Barriers to Effective Treatment
Impediments to the use of opioids for pain relief include patients’
reluctance to use opioids, the healthcare system’s inadequate
reimbursement and low priorities for pain treatment, and physicians’
concerns about addiction, tolerance, diversion, management of side
effects, and fear of regulatory scrutiny.15-17
Patient Barriers. Patients may be reluctant to report pain because
of fear that pain means worsening disease or concern about not being a
“good” patient. They may be reluctant to take opioid medications because
of concerns about addiction or side effects.
System Barriers. Contributing factors include availability or
access to treatment, inadequate reimbursement, the low priority given to
chronic malignant and nonmalignant pain treatment, and restrictive
regulation of controlled substances.
Clinician Barriers. Physicians’ knowledge about pain assessment and
treatment, and management of side effects may not be adequate, and may
lead to undertreatment of patients. Reluctance to prescribe controlled
substances was reported by 61% of physicians in a survey from the Eastern
Cooperative Oncology Group.18 Such reluctance may be due to concerns about
physical dependence, tolerance, addiction, pseudoaddiction, and diversion.
15-17 ·
Physical Dependence is a pharmacologic effect characteristic of
opioids. Abrupt discontinuation of the medication usually results in the
manifestation of abstinence, or withdrawal, syndrome. Physical dependence
does not independently cause addiction.15
Tolerance. It was previously thought that the development of
analgesic tolerance limited the ability to use opioids efficaciously on a
long-term basis for pain management. Tolerance, or decreasing pain relief
with the same dosage over time, has not proven to be a prevalent
limitation to long-term opioid use. Experience with treating cancer pain
has shown that what initially appears to be tolerance is usually
progression of the disease. Furthermore, for most opioids, there does not
appear to be an arbitrary upper dosage limit, as was previously thought.15
Addiction. Misunderstanding of addiction and mislabeling of
patients as addicts result in unnecessary withholding of opioid
medications. Addiction is a compulsive disorder in which an individual
becomes preoccupied with obtaining and using a substance, the continued
use of which results in a decreased quality of life. Studies indicate that
the de novo development of addiction when opioids are used for the relief
of pain is low. Furthermore, experience has shown that known addicts can
benefit from the carefully supervised, judicious use of opioids for the
treatment of pain due to cancer, surgery, or recurrent painful illnesses
such as sickle cell disease.15,19 achieved.15
Pseudoaddiction is a frequent consequence of undermedication and
typically disappears once adequate pain relief is achieved.15
Diversion. Although diversion of controlled substances should be a
concern of every health professional, efforts to stop diversion should not
interfere with prescribing opioids for pain management. Documentation of
patterns of prescription requests and the prescribing of opioids as part
of an ongoing relationship between a patient and a healthcare provider can
decrease the risk of diversion.17
Major Educational Needs Inferred from the Literature
Chronic malignant and nonmalignant pain continues to be undertreated in
many patients. Many practitioners are not well trained in pain
pathophysiology or drug pharmacokinetics. Many practitioners continue to
maintain a negative perception of opioids for the treatment of chronic
pain. Because of concerns about addiction and side effects, many patients
do not disclose their level of pain to physicians. Cost issues are an
increasing problem in treatment decisions for physicians as well as for
patients. To resolve common problems associated with the care of
intractable pain, education is important for all members of the pain
treatment team, including pain specialists, oncologists, primary care
providers, and nurses, as well as pharmacists and caregivers. Continuing
medical education programs should focus on the following areas:
•critical importance
of treating chronic pain
•effective pain management as an
integral aspect of quality medical care
•dispelling common myths associated
with pain control
•proper assessment of pain
•assessment and management of aberrant
drug-related behavior
•formulations and regimens available
for treatment of chronic pain
•use of pharmacologic agents,
particularly opioids
•strategies for managing side effects
of analgesic agents
•understanding of the specific
restrictions of controlled substances statutes and practice guidelines
to ensure that the use of opioid analgesics is within established legal
parameters and compatible with best medical practice.
While general information may be offered in various
formats, local education is also important. Treatment of
moderate-to-severe pain with opioids is regulated by the Drug Enforcement
Agency (DEA). States have varying regulations concerning prescribing
practices, with some states requiring triplicate scripts, of which one
copy goes to the DEA. States may regulate the quantity of opioids
prescribed or the manner in which the prescription is written.17 Because
of the numerous regulations imposed on schedule II analgesics by state
authorities, health care professionals may need education on their local
requirements regarding opioid prescriptions.
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