How to manage chronic pain and prevent opioid misuse

Opioids are potent pain relievers and are often prescribed for acute pain, particularly in emergency departments and following surgical procedures. Moreover, millions of adults are currently prescribed opioids for chronic pain (typically defined as pain of at least moderate intensity lasting longer than 3 months), which impacts approximately 11% of adults in the United States. The result is that health-care providers have to struggle to balance the goal of providing appropriate pain relief with the goal of minimizing the number of people who transition to opioid misuse and opioid use disorder.

Current strategies to achieve this balance include the identification of risk factors for opioid misuse, best practices for surgery recovery, and enhanced use of nonopioid pain control strategies.

Risk factors for opioid misuse

Concerted research efforts have been devoted to identifying individuals at risk for misuse of prescription opioids. These include:

• Family history of substance use disorder
• Personal history of substance use disorder
• Younger age
• History of criminal activity and/or legal problems including DUIs
• Regular contact with risky environments or situations (e.g., exposure to other people misusing opioids)
• Interpersonal problems with past employers, family members, and friends
• Risk taking or thrill-seeking behavior
• Heavy tobacco use
• History of severe depression or anxiety
• Psychosocial stressors

A number of regulatory and professional organizations have provided recommendations and guidelines for the use of opioids among patients with chronic pain. These guidelines emphasize the importance of opioid risk assessment before initiation of long-term opioid therapy.

In addition to performing a thorough history and a review of past medical records, conducting an opioid risk assessment using validated screening tools is recommended. Structured interview measures based on Diagnostic and Statistical Manual of Mental Disorders criteria have been useful in assessing substance use disorders, but these measures often lack validation with persons with chronic pain. Using traditional substance use disorder measures increases the likelihood that physiological tolerance and dependence (i.e., requiring more opioids to achieve the same effect and/or withdrawal symptoms when the medication is decreased or discontinued) will be identified when no misuse exists. Several screening tools are available that are specifically developed for people with pain:

Nonpharmacological alternatives for acute and chronic pain

• The most widely studied and efficacious interventions for chronic pain include cognitive behavioral therapy and other behavioral interventions (e.g., acceptance and commitment therapy, exposure to feared movements), exercise, physical therapy, and interdisciplinary rehabilitation. Depending on the pain condition, other therapies with evidence of efficacy include mindfulness-based interventions, yoga, biofeedback, tai chi, acupuncture, spinal manipulations, and massage. Ongoing research is needed to identify new postsurgery strategies such as immersive distraction techniques to further reduce the need for other pain control.
• Superficial heat and cryotherapy can help reduce the intensity of both acute and chronic pain.
• Transcutaneous electrical nerve stimulation (TENS) has also been shown to be effective for acute pain, and there is mixed evidence of TENS efficacy as a treatment for chronic pain. Relaxation and distraction have been used to good effect in medical and dental settings involving acute pain or discomfort, such as injections or teeth cleaning.

Nonopioid pharmacological alternatives for acute pain

• Several recent studies have found combinations of acetaminophen and ibuprofen, as well as other nonsteroidal anti-inflammatory medications, to be as effective as opioid medications for managing acute pain in multiple settings where opioids are often used as the primary treatment option.
• Even in palliative care for patients with cancer, the World Health Organization recommends nonopioid pain relievers, including acetaminophen or ibuprofen, as the preferred first step for providing pain relief.
• Other pharmacological options for acute pain include a low dose of ketamine, nitrous oxide, intravenous lidocaine, or gabapentin and pregabalin.

Nonopioid pharmacological alternatives for chronic pain

• There is little evidence to support the use of long-term opioid therapy in the treatment of chronic noncancer pain. Based on the lack of evidence in support of opioids for chronic noncancer pain and the considerable risks of harm posed by misuse of opioid prescriptions, the Centers for Disease Control and Prevention recommends nonpharmacological treatments or nonopioid pharmacological treatments be considered as the initial treatment approach for chronic painopens in new window.
• Nonopioid alternatives include but are not limited to, acetaminophen, nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen), amine reuptake inhibitors (e.g., fluoxetine, paroxetine), membrane stabilizers (e.g., gabapentin, pregabalin), and muscle relaxants (for short-term relief). Lidocaine patches, topical capsaicin cream, and subcutaneous injections of botulinum toxin type A have also been shown to provide pain relief for some chronic pain conditions. Recent research has indicated that these nonopioid alternatives are at least as efficacious as opioids for low back pain and are less associated with adverse events.