Treatment goals should be established and understood by the prescriber and patient prior to initiation of opioids.28 Overarching treatment goals for all opioids prescribed are pain relief (but not necessarily a focus on pain scores), improvement in functional activity, and minimization of adverse effects, with the latter 2 goals taking precedence.31 To assess outcomes, formally measure progress toward goals from baseline evaluations. This can be achieved through repeated use of validated tools such as those mentioned earlier, or may be more broadly considered as progress toward employment status or increasing participation in activities.31 All pain management plans involving opioids should include continued efforts with nonpharmacologic therapy (eg, exercise therapy, weight loss, behavioral training) and nonopioid pharmacologic therapy (eg, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, anticonvulsants).28
Have an “exit strategy.” As part of goal setting, also consider how therapy will be discontinued if benefits do not outweigh the risks of harm.28 Weigh functional status gains against adverse opioid consequences using the PEG scale (pain, enjoyment of life, and general activity) (TABLE 232).33 Improvements of 30% from baseline have been deemed clinically meaningful by some,32 but not all benefits will be easy to quantify. At the start of treatment dialogue, use the term “therapeutic trial” instead of ”treatment plan” to more effectively convey that opioids will be continued only if safe and effective, and will be prescribed at the lowest effective dose as one component of the multimodal approach to pain.30
Initiation of treatment: Opioid selection and dosing
When initiating opioid therapy, prescribe an immediate-release, short-acting agent instead of an ER/LA formulation.28
For moderate pain, first consider tramadol, codeine, tapentadol, or hydrocodone.31 Second-line agents for moderate pain are hydrocodone or oxycodone.31
For severe pain, first-line agents include hydrocodone, oxycodone, hydromorphone, or morphine.31 Second-line agents for severe pain are fentanyl and, with careful supervision or referral to a pain specialist, methadone or buprenorphine.31
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