Acute Pain
Chronic Pain
Is this patient at High Risk of developing chronic pain?
Consider:
1) Do I need to see this patient more Frequently?
2) Should I use a Pain Assessment Template?
3) Should I assess for mood disorders?
4) If not progressing as expected or if considering initiation of opiod medications, consider moving to the Acute 2 pain management module. If duration of pain is greater than 3 months, consider using one of the Chronic Pain management modules.
Patient Not Responding as expected
1) Reviewing patient using a Pain Assessment Template.
2) Looking for Red Flags.
3) Looking for Yellow Flags.
4) Assessing patient with appropriate tools.
5) Have you done an Adequate Exam?
8) Are you Thinking of starting opiods?
a) Morphine Equivalent Dose
Daily dose morphine is greater than 50mg. As per CDC recommendations, increase frequency of follow-up and consider offering naloxone kit.
b) Opioid use checklist 1) UDT/Pharmanet protocol in place 2) Risk assessment 3) Mental Health Assessment 4) Opioid Approach 5) Opioid Information 6) Opioid Agreement
d) Consider: Review of patient agreed treatment goals for pain and function/BAP annually
e) When to stop f) How to switch g) How to stop
7) Pain Careplan/Summary
Precontemplative Patient
2) Is patient on opioid medications?
A) Morphine Equivalent Dose
B) Opioid use checklist 1) UDT/Pharmanet protocol in place 2) Risk assessment 3) Mental Health Assessment 4) Opioid Approach 5) Opioid Information 6) Opioid Agreement
D) Consider: Review of patient agreed treatment goals for pain and function/BAP annually
E) When to stop F) How to switch G) How to stop
3) Pain Careplan/Summary
Contemplative Patient
2) Consider: a) Mood assessment every 6 months b) Screening as appropriate every 12 months c) Asking about alcohol or drug use even if not on opioids d) Pie of Life, Unhelpful Thinking etc e) Brief Action Planning every 6 months f) Other management tools ToolBox g) Disease specific educational information if patient is interested h) Asking patient to book for CPX to ensure current assessment is complete and accurate with review of red and yellow flags.
3) Is patient on opioid medications?
4) Pain Careplan/Summary
Engaged Patient
2) Work on: a) Regularly validate the patients pain experience by taking time to listen and being empathetic (consider doing a BPI). b) Help patient set a management plan with focus on improving functional status (consider Pie of Life, Live Plan Be in handouts). c) Set realistic goals at each visit and positively reinforce success with the achievement of these goals. d) Continually be alert for co-morbities and treat as needed. e) Review previous treatments and specific responses with an aim to optimization.
Summary of this visit
Information for patient:
Open Communication Box Choosing Wisely Dr Evans Pain BC Pain Fundamentals Live Pain Be
Opioid videos Opioid Use Video Opioid Safety Video
Scripts
Acute1 Acute2 Precontemplative Contemplating Preparation Action Maintenance Relapse Show all
Empathy Strategies Holistic Function Pain Relievers Fear
History Factors Fears Expectations High Risk Medications Non-Pharmacologic Angry/argumentative
Change Readiness Change Prompting Education Hope Medications High Risk Fears Angry/argumentative
Change Readiness Change Prompting Collaboration Encouragement Education Medications Goal Setting Fears
Change Education(basic) Education(advanced) Medications Non pharmacologic Return to function Collaborate/Encourage
Calculate Reset
When to stop Risks Outweighs Benefits/Adverse Effects/Medical Complications/Opioid Not Effective Examples and Considerations 1) Patient receives definitive treatment for condition. A trial of tapering is warranted to determine if the original pain condition has resolved. 2) Overdose risk has increased. 3) Clear evidence of diversion. 4) Aberrant drug related behaviours have become apparent. 5) Adverse effects impairs functioning below baseline level. 6) Medical complications have arisen (e.g. hypogonadism, sleep apnea, opioid induced hyperalgesia) 7) Opioid effectiveness has not resulted in improved function or at least 30% reduction in pain intensity 8) Pain and function remains unresponsive. 9) Opioid being used to regulate mood rather than pain control. 10) Periodic dose tapering or cessation of therapy should be considered to confirm opioid therapy effectiveness
How to Stop 1) How do I stop? The opioid should be tapered rather than abruptly discontinued. 2) How long will it take to stop the opioid? Tapers can usually be completed between 2 weeks to 4 months. 3) When do I need to be more cautious when tapering? Pregnancy:Acute opioid withdrawal has been associated with premature labour and abortion. 4) How do I decrease the dose? Decrease the dose by no more than 10% of the total daily dose every 1-2 weeks. Once one-third of the original dose is reached, decrease by 5% every 2-4 weeks. Avoid sedative-hypnotic drugs, especially benzodiazepines, during the taper.
How to Switch Opioids If previous opioid dose was high: start with 50% or less of previous opioid dose (converted to morphine equivalent) If previous opioid dose was moderate or low: start with 60-75% of the previous opioid dose(converted to morphine equivalent)
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