Pain Management in an Opioid Epidemic: What’s Appropriate, What’s Safe

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On January 1, 2018, The Joint Commission (JNC) implemented new and revised standards to ensure that all patients receive appropriate assessment and management of their pain. While these standards apply to accredited hospitals, they provide a solid framework for assessing and treating pain in any patient. JNC now requires that patients be included in the development of treatment plans, which should encompass realistic expectations and reasonable goals, and that providers promote safe opioid use by identifying and monitoring high-risk patients.11

One valuable tool that can help clinicians fulfill the obligation to provide safe and effective pain management is the World Health Organization’s “pain ladder” (see Figure 1).12 Originally released in 1986 to address cancer pain in the pediatric population, this tool has proven validity. It has since been expanded to guide treatment of pain in other patient populations. In addition, the steps of the “pain ladder” provide useful information on the clinical examination and documentation of pain, principles of pharmacotherapeutic management, and considerations when using different analgesics.

The WHO Three-step Pain Ladder image

Pain is assessed on a scale of 1 to 10, with 1 representing the least pain. Medication recommendations are as follows

  • For mild pain (ie, a score of 1-3): acetaminophen, NSAIDs, or other nonopioids.
  • For moderate pain (pain score, 4-6): an opioid (eg, hydrocodone), with or without an adjunct medication.
  • For severe pain (pain score, 7-10) or pain that has not responded to previous therapies: a stronger opioid (eg, morphine, hydromorphone, fentanyl), with or without an adjuvant drug.12

In all cases, patients should be informed about both pharmacotherapeutic and nonpharmacotherapeutic options. The latter include hypnosis, relaxation techniques, acupuncture, physical therapy, application of heat and cold, and electro-analgesia.

Pharmacologic options at any “step” of the ladder carry the risk for adverse effects. Thus, NPs and PAs who prescribe these medications need to apprise patients of the potential harms associated with their treatment.

Acetaminophen. Patients should be instructed on the safe use of acetaminophen, particularly with regard to dosing, since liver damage can occur. Patients should not take more than 4,000 mg in a 24-hour period, and each dose should not exceed 1,000 mg.

NSAIDs. These drugs are often used for short-term management of mild and moderate pain. Patients should be instructed to take these agents with food to decrease GI upset. Other common adverse effects include GI bleed or perforation and renal insufficiency or failure.

Opioids. Depending on which class of receptors an opioid medication targets, patients may develop any of the following: constipation, decreased GI motility, nausea, hypotension, urinary retention, euphoria, pruritus, miosis, dependence, respiratory depression, and sedation. It is important for NPs and PAs who prescribe these medications to remain vigilant for adverse effects and complications from opioid use and to educate the patient and his/her family about possible complications.6

Patients must be instructed not to drink alcohol or take other CNS depressants while taking an opioid. They should be advised about the dangers of operating heavy equipment or engaging in other activities that require mental and physical alertness, since opioids can cause drowsiness. Among the GI effects of some opioids (nausea, vomiting) is constipation—so patients should also be educated on the need to increase fluid intake and include high-fiber foods in their diet.9

But most important of all, patients taking an opioid should be informed that there is the potential for physical dependency and abuse with these agents, and these agents should be used only for acute, severe pain.


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