Options to Opioids

from Universal Precautions in Pain Medicine: The Treatment of Chronic Pain With or Without the Disease of Addiction, Gourlay DL et al; Pain Med 2005; 6:107-112

The following universal precautions are recommended as a guide for all healthcare professionals who prescribe Schedule II medications to treat chronic medical problems, including pain. As with universal precautions in infectious diseases, by applying the following recommendations, patient care may be improved, stigma reduced, and overall risk contained.

The 10 Steps of Universal Precautions in Pain Medicine

1. Make a Diagnosis With Appropriate Differential. Treatable causes for pain should be identified when they exist, and therapy should be directed to the cause of pain. Any comorbid conditions, including substance use disorders and other psychiatric illnesses, must also be addressed.
2. Psychological Assessment, Including Risk of Addictive Disorders. A complete inquiry into past personal and family history of substance misuse is essential to adequately assess any patient. A sensitive and respectful assessment of risk should not be seen in any way as diminishing a patient's complaint of pain. Patient-centered urine drug testing should be discussed with all patients regardless of the medications that they are currently taking.[9] Patients found to be using illicit or unprescribed licit drugs should be offered further assessment for possible substance use disorders. Those refusing such assessment should be considered unsuitable for pain management with a controlled substance.
3. Informed Consent. The healthcare professional must discuss the proposed treatment plan with patients and answer any questions that they may have about its anticipated benefits and foreseeable risks.
4. Treatment Agreement. The expectations and obligations of both the patient and the treating practitioner need to be clearly set forth in writing or by verbal agreement. Combined with informed consent, the treatment agreement forms the basis of the therapeutic trial. A carefully worded treatment agreement will help to clarify appropriately set boundary limits making possible early identification and intervention around aberrant behaviors.[10,11]
5. Pre- or Post-Intervention Assessment of Pain Level and Function. It must be emphasized that any treatment plan must begin with a trial of therapy. This is particularly true when controlled substances are contemplated or used. Without a documented assessment of preintervention pain scores and level of function, it will be difficult to assess success in any medication trial. The ongoing assessment and documentation of successfully met clinical goals will support the continuation of any mode of therapy. Failure to meet these goals will necessitate reevaluation and possible change in the treatment plan.
6. Appropriate Trial of Opioid Therapy With or Without Adjunctive Medication. Pharmacologic regimens must be individualized on the basis of subjective as well as objective clinical findings. The appropriate combination of agents, including opioids and adjunctive medications, may be seen as "rational pharmacotherapy" and provide a stable therapeutic platform from which to base treatment changes.
7. Reassessment of Pain Score and Level of Function. Regular reassessment of the patient combined with corroborative support from family or other knowledgeable third parties will help document the rationale to continue or modify the current therapeutic trial.
8. Regularly Assess the "4 A's" of Pain Medicine. Routine assessment of analgesia, activity, adverse effects, and aberrant behaviors will help to direct therapy and support pharmacologic options taken.[12]
9. Periodically Review Pain Diagnosis and Comorbid Conditions, Including Addictive Disorders. Underlying illnesses evolve. Diagnostic tests change with time. As a result, treatment focus may need to change over the course of time. If an addictive disorder predominates, aggressive treatment of an underlying pain problem will likely fail if not coordinated with treatment for the concurrent addictive disorder.
10. Documentation. Careful and complete recording of the initial evaluation and each follow-up is both medicolegally indicated and in the best interest of all parties. Thorough documentation combined with an appropriate doctor-patient relationship will reduce medicolegal exposure and risk of regulatory sanction.