Pain Management in Primary Care: Strategies to Mitigate Opioid Misuse, Abuse, and Diversion
Chronic Pain Management Program, Kaiser Permanente, San Diego, CA, USA.Postgraduate Medicine (Impact Factor: 1.7). 03/2011; 123(2):119-30. DOI: 10.3810/pgm.2011.03.2270
Pain is among the most common reasons patients seek medical attention, and the care of patients with pain is a significant problem in the United States. Acute pain (mild-to-moderate intensity) represents one of the most frequent complaints encountered by primary care physicians (PCPs) and accounts for nearly half of patient visits. However, the overall quality of pain management remains unacceptable for millions of US patients with acute or chronic pain, and underrecognition and undertreatment of pain are of particular concern in primary care. Primary care physicians face dual challenges from the emerging epidemics of undertreated pain and prescription opioid abuse. Negative impacts of untreated pain on patient activities of daily living and public health expenditures, combined with the success of opioid analgesics in treating pain provide a strong rationale for PCPs to learn best practices for pain management. These clinicians must address the challenge of maintaining therapeutic access for patients with a legitimate medical need for opioids, while simultaneously minimizing the risk of abuse and addiction. Safe and effective pain management requires clinical skill and knowledge of the principles of opioid treatment as well as the effective assessment of risks associated with opioid abuse, addiction, and diversion. Easily implementable patient selection and screening, with selective use of safeguards, can mitigate potential risks of opioids in the busy primary practice setting. Primary care physicians can become advocates for proper pain management and ensure that all patients with pain are treated appropriately.
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ABSTRACT: Chronic opioid therapy presents potential benefits to the patient with chronic noncancer pain. Clearly, chronic opioid therapy has risks such as misuse, abuse, and diversion. Screening tools have been developed to define patients at risk for, predict, and detect these negative outcomes. Careful study demonstrates that the tools and their application in clinical practice are imperfect and often fail to fulfill their promise. Barriers to their success range from limited psychometric capabilities to the presence of confounding psychiatric comorbidities. However, the essence of poor outcome in the care of patients with chronic noncancer pain is the inexperience of the practitioner with chronic opioid therapy and the lack of a comprehensive approach to case formulation. The care of patients can only reach its full potential if practitioners follow a standardized approach repeatedly with ongoing reflection about why a particular outcome occurred, what they could do differently, and how a coherent evidence-based rationale supports their recommendations. This iterative process will refine clinical practice and produce experts in pain management.01/2012; 5(S2):329 - 334. DOI:10.1016/j.eujps.2011.08.001
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ABSTRACT: The concurrent rise of undertreated pain and opiate abuse poses a unique challenge to physicians and researchers alike. A focal, noninvasive form of brain stimulation called repetitive transcranial magnetic stimulation (rTMS) has been shown to produce acute and chronic analgesic effects when applied to dorsolateral prefrontal cortex (DLPFC), but the anatomical and pharmacological mechanisms by which prefrontal rTMS induces analgesia remain unclear. Data suggest that DLPFC mediates top-down analgesia via gain modulation of the supraspinal opioidergic circuit. This potential pathway might explain how prefrontal rTMS reduces pain. The purpose of this sham-controlled, double-blind, crossover study was to determine whether left DLPFC rTMS-induced analgesia was sensitive to μ-opioid blockade. Twenty-four healthy volunteers were randomized to receive real or sham TMS after either intravenous saline or naloxone pretreatment. Acute hot and cold pain via quantitative sensory testing and hot allodynia via block testing on capsaicin-treated skin were assessed at baseline and at 0, 20, and 40 minutes after TMS treatment. When compared to sham, real rTMS reduced hot pain and hot allodynia. Naloxone pretreatment significantly reduced the analgesic effects of real rTMS. These results demonstrate that left DLPFC rTMS-induced analgesia requires opioid activity and suggest that rTMS drives endogenous opioidergic pain relief in the human brain. Further studies with chronic dosing regimens of drugs that block or augment the actions of opiates are needed to determine whether TMS can augment opiates in chronic or postoperative pain management.Pain 03/2012; 153(6):1219-25. DOI:10.1016/j.pain.2012.02.030 · 5.21 Impact Factor
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ABSTRACT: Prescription opioid analgesic therapy can be effective in managing chronic noncancer pain in appropriately selected patients. However, the risks and benefits of prescription opioids should be carefully considered when treating this patient population. A dramatic increase in opioid-related morbidity and mortality has been observed in the United States in the past decade. Therefore, health care providers must balance the treatment of chronic pain with the need to minimize the risks of opioid misuse, abuse, addiction, and diversion. Current literature suggests that most patients with chronic pain are managed at the primary care level. However, many of these practitioners are not skilled in risk assessment, stratification, and monitoring. This article reviews strategies and tools that providers may implement to help identify appropriate patients for chronic opioid therapy and recognize signs of drug-related aberrant behaviors and abuse. In addition, the potential role of abuse-deterrent, extended-release opioid formulations to reduce risk in patients and nonmedical users of opioids is introduced. Collectively, these preventative measures may effectively reduce opioid misuse, abuse, and diversion without denying adequate analgesia in appropriate patients.Postgraduate Medicine 05/2012; 124(3):131-8. DOI:10.3810/pgm.2012.05.2556 · 1.70 Impact Factor
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