Chronic Pain

Chronic pain

Pain lasting >3-6 months

First-line approach to chronic pain

Non-pharmacologic + non-opioid therapy

When are opioids appropriate?

When pain is uncontrolled despite optimized non-opioid therapy OR contraindications exist

Initial opioid strategy (opioid-naïve)

Start low-dose immediate-release opioid

Tolerance

Decreased response requiring higher doses

Dependence

Withdrawal symptoms when drug is stopped

Mechanism of opioid tolerance

Mu receptor desensitization

Incomplete cross-tolerance

Increased sensitivity when switching opioids

Opioid rotation dose reduction

Reduce new opioid dose by 25-50%

When to use 50% reduction

Patient pain was well controlled, but are switching due to intolerable ADEs

Switching from a high opioid dose

Patient is elderly or medically fragile

When to use 25% reduction

Pain is not well controlled at switch

Breakthrough opioid dosing

10-15% of total daily dose (TDD)

Steps in opioid rotation

Calculate MME → convert → reduce 25-50% → add breakthrough

Reason for opioid rotation

Poor pain control, ADEs, drug interactions, cost, route change, Improve adherence/convenience (e.g., switch to ER)

NSAID exception for chronic use

Ketorolac (max 5 days)

Best drugs for neuropathy + depression

SNRIs (duloxetine, venlafaxine)

Best drugs for neuropathy alone

Gabapentin or pregabalin

Best drugs for neuropathy + anxiety

Muscle relaxant use duration

Short-term only (1-2 weeks)

Gabapentin counseling

Takes 2-6 weeks, causes sedation, do not stop abruptly

Opioid taper (long-term use)

10% per month

Opioid taper (short-term use)

10% per week

When to taper opioids

No benefit, ≥50 MME without improvement, misuse, ADEs, patient request

Opioid-induced constipation first-line

Stimulant laxative + stool softener

Avoid in OIC

Bulk-forming laxatives (psyllium)

Top times to check PMP

New patient, controlled substance, chronic pain, misuse concerns, Patient is in substance abuse treatment, evaluating episodic care

Key action after concerning PMP findings

Talk with patient and coordinate care

Post PMP Review Action Steps for at Risk Patients

• TALK with the patient to determine reasons for at risk behaviors

• COODINATE care with the other providers listed on the report

• CONSIDER using a patient treatment agreement

• VERIFY the prescriptions listed match your records

• REFER your patient to treatment or other specialty care

• EDUCATE patients on the risks of opioid overdose

Pain contract

Agreement between provider and patient outlining expectations for opioid use

Purpose of pain contract

Improve adherence, reduce misuse, and set clear rules

Examples of pain contract components

Single provider/pharmacy, no early refills, adherence to dosing, monitoring compliance

When to use a pain contract

Initiating or continuing chronic opioid therapy

Online opioid calculators purpose

Calculate MME and guide safe opioid dosing/conversions

Why are MME calculators important?

Help reduce overdose risk by standardizing opioid dosing