DURING OPIOID THERAPY: ASSESS HARMS, FOLLOW-UP, AND DISCONTINUATION

(Dowell et al., 2016)

+ Evaluate benefits and harms within 1–4 weeks of starting opioid therapy. Continue to reevaluate the opioid therapy at least every 3 months. Evaluate patients with higher risk of opioid use disorder more often.

+ Urine drug testing is recommended when initiating opioid therapy and at least annually for all patients on long-term pain therapy.

When discussing urine drug testing, be empathetic and focus on patient safety. If a urine drug test is abnormal, before making a treatment decision, remember to consider what the patient is reporting and order confirmation testing. False positives with point-of-care urine drug screening can be common and must be confirmed with gas chromatography–mass spectrometry testing (Yu, 2015).

+ Continue therapy only if there is clinically meaningful improvement in pain and function that outweighs the risks to patient safety.

+ All patients should receive baseline and intermittent depression and anxiety screenings. Patients with pain and behavioral health comorbidities face challenges that can exacerbate painful conditions (de Heer et al., 2014; Murez, 2021).

+ When opioid therapy needs to discontinue, but no illicit drug use or abuse has been confirmed, taper the opioids slowly to minimize symptoms and signs of opioid withdrawal.

+ If illicit drug use or prescription abuse is confirmed, strongly consider a referral to an addiction or pain management specialist. Prescribing should be discontinued.

MULTIDISCIPLINARY PAIN MANAGEMENT Treatment Alternatives to Opioids for Native Patients

Native patients may experience and manage their pain differently than those in the dominant culture. Native patients have reported dissatisfaction with standard pain scales and questionnaires; pain often encompasses social and

“For Native patients...pain often encompasses social and spiritual qualities that cannot be reflected through a number on a pain scale.” spiritual qualities that cannot be reflected through a number on a pain scale (Jimenez et al., 2011). Improving trust and communication is an important step in improving pain management for Native patients. Therefore, providers should consider nonopioid treatment paths when managing pain in Native patients (see Table 1). A few things to consider are listed in the sections below.

MEDICATIONS.

The goal is to limit adverse outcomes while ensuring patients have access to medication-based treatment that can enable a better quality of life and function. The choice of medication should be based on the pain diagnosis, the pain mechanisms, and any related comorbidities following a thorough history, physical exam, other relevant diagnostic procedures, and a risk–benefit assessment that demonstrates the benefits of a medication outweighs its risks (Dowell et al., 2016).

LIST OF NONOPIOID MEDICATIONS THAT CAN BE USED TO TREAT PAIN:

+ Acetaminophen

+ Anticonvulsants

+ Nonsteroidal antiinflammatory drugs

+ Topical agents

+ Tricyclic antidepressants

+ Serotonin–norepinephrine reuptake inhibitors

Note. This list is not all-inclusive or prescriptive.

Nonpharmacological Approaches To Pain Management

Treatment approaches that incorporate psychological, social, and cultural interventions along with physical interventions are more effective for reducing longterm pain and disability compared with usual care or physical therapy alone (Dowell et al., 2016).

+ Restorative therapies: Practices implemented by physical therapists and occupational therapists (e.g., physiotherapy, therapeutic exercise, and other movement modalities), chiropractic care, and osteopathic manipulative therapies are valuable components of multidisciplinary, multimodal acute and chronic pain care (Dowell et al., 2016).

+ Interventional approaches: Interventional approaches including image-guided and minimally invasive procedures are available as diagnostic and therapeutic treatment modalities for acute, acute on chronic, and chronic pain when clinically indicated. The various types of these procedures include trigger point injections, radiofrequency ablation, cryoneuroablation, neuromodulation (Mukund et al., 2019).

+ Behavioral health approaches: Psychological, cognitive, emotional, behavioral, and social aspects of pain can have significant effects on treatment outcomes.

+ Complementary and integrative health: Treatment modalities such as acupuncture, massage, movement therapies (e.g., yoga, tai chi), and spirituality should be considered when clinically indicated. (Jimenez et al., 2011)

+ Spiritual aspects: Spiritual aspects of care are an important part of Native American patients’ healing practices. Respectfully talk to the patient about their relationship to traditional healing (see Table 2). Be open and nonjudgmental. Cultural connections can bring peace and healing (Duwe, 2019).

Tips For Talking To Patients About Their Use Of Traditional Healing Techniques

+ Use a patient-centered approach.

+ Ask permission to ask more about culture and beliefs.

+ Take cues from the patient on their comfort level.

+ Consult with others and maintain education.

+ Include culturally relevant questions in patient intake questionnaire.

+ Be nonjudgmental.

+ Allow plenty of time for discussion or storytelling.

+ Try to use the language that the patients uses.

+ Be open with the patient about the limited knowledge of traditional healing techniques.

+ Thank the patient for sharing their experiences.

Treating Patients In Recovery

The provider may consider referring a patient in recovery to an addiction specialist for assistance with treatment. However, this may not always be feasible due to rural locations or provider shortages. When an addiction specialist is the prescriber of analgesics, medical responsibilities (e.g., prescribing of analgesics, physical therapy, orthotics) should be coordinated with the clinician responsible for other components of the pain treatment (Center for Substance Abuse Treatment, 2012). Goals for treating chronic pain in patients who are in recovery are as follows:

+ Include the patient in conversations around the treatment plan. Use language that focuses on health and safety. Avoid judgment and stigmatization. Motivational interviewing skills can be useful here. More information about motivational interviewing is listed in the Resources section.

+ Treat chronic, noncancer pain with nonopioid analgesics as determined by pathophysiology.

+ Recommend or prescribe nonpharmacological therapies (e.g., cognitive–behavioral therapy [CBT], exercises to decrease pain and improve function).

+ Treat comorbidities.

+ Initiate opioid therapy only if the potential benefits outweigh the risks and only for as long as is unequivocally beneficial to the patient. Educate patients on the risk of opioid dependence, overdose, and death as well as on the safe storage of medication.

+ Assess treatment outcomes.

In addition, use of the Oklahoma Prescription Monitoring Program (PMP) is advised when treating patients. The PMP is discussed in more detail in Section 2.

A Pocket Book Guide For Prescribers

Prescribing for Non-Palliative Care

Laws & Policies of Safer Opiod