We are going to focus on chronic pain. Acute pain is another topic and discussion for another time.
First it is important to note that no one wants a patient to be in pain. However, your Provider has the responsibility to determine not only if there is a need for pain management but also the level of need and the appropriate combination of pain medications that are required to treat the pain while also keeping the patient safe.
1. Balance Risk vs. Benefit:
Your Provider will determine if an opioid should or should not be started. There is a delicate balance of risk versus benefit that your Provider must evaluate when establishing a regimen to treat pain. Your Provider knows just because they can add a medication does not always mean they should. Opioids are dangerous and their need must be carefully weighed. Opioid medications and their risk of sedation as well as respiratory depression stack or compound each other requiring the Provider to vigilant in ensuring the safety of the patient.
2. Will individualize and ensure a patient centered treatment plan:
Your Provider will individualize the treatment to help patients achieve a preferred quality of life while minimizing risk with Opioids. Pain is so complex. There are so many variables for your Provider to consider, which is why treatment should be individualized and patient centered.
If a Provider determines to start an opioid, a Provider will start at the most conservative and lowest effect dose and for the least amount of time needed.
For patients that have already been on long term opioid therapy, your Provider will weigh out the benefits and risks of continuing current doses, tapering down opioid doses to a safer dose or discontinuing the opioids entirely.
3. Maximize the Non-Opioid Treatment 1st:
Non-opioid treatments can be just as effective as opioid treatments. The treatment plan will try to maximize the benefits of non-opioid treatments prior to utilizing opioid treatments.
Your Provider will also determine the cause or origin of your pain and will start with medications that will target the specific source. Nerve pain for example is more adequately treated with non-opioid treatments. Your Provider will utilize therapies that will target nerve pain such as gabapentin, Lyrica©, Cymbalta© or amitriptyline. It is important to remember that these medications used to treat nerve pain, take a little more time to reach therapeutic levels to give the most benefit. Ask your provider for realistic expectations and a timeline on when you should start to feel some relief. Some of these medications can take weeks so it is important to give them the needed time to reach maximum benefits.
Non-opioid treatments will also include topical creams/gels and oral anti-inflammatory treatments such as ibuprofen. Utilizing both anti-inflammatory medications in addition to acetaminophen can help to elevate much of the pain.
Non-pharmacological treatments such as mindfulness, massage or acupuncture, physical therapy and exercise.
4. Frequent Follow up will be necessary.
If Opioids have been initiated and determined to be a long term solution, your Provider will continue to evaluate and balance the need for continue opioid to maintain pain control versus the risk. Ideally the minimal dose required will be used in order to maintain the pain control as well as quality of life. One tool Providers use to evaluate and compare opioid doses are Morphine Equivalents.
What are Morphine Equivalents?
Morphine equivalents are a way of comparing opioid medications. Not all opioid medications are identical in strength. For example 10mg of oxycodone=15mg of morphine equivalents where 10mg of hydrocodone=10mg of morphine. Your Provider will use morphine equivalents to convert an opioid's strength to a common value to ensure doses are not too high and the dosing is safe and appropriate to use. Higher doses does not only not give better pain relief but also increases risk of overdoses. The 2022 Clinical Practice Guideline for Prescribing Opioids for Pain advises Providers to be cautious in prescribing more than 50mg of Morphine Equivalents per day due to it being a point where the risk then exceeds the benefit of the opioid.
" Many patients do not experience benefit in pain or function from increasing opioid dosages to ≥50 MME/day but are exposed to progressive increases in risk as dosage increases. Therefore, before increasing total opioid dosage to ≥50 MME/day, clinicians should pause and carefully reassess evidence of individual benefits and risks. If a decision is made to increase dosage, clinicians should use caution and increase dosage by the smallest practical amount."
What is Narcan© (naloxone) and why it is so important...
Naloxone is a nasal spray that one can use to block and reverse the opioid. Naloxone can save lives. Just as an EpiPen© can help save lives of those which extreme allergic reactions, Narcan© can save lives of patients with an Opioid Overdose.
Everyone should consider having a naloxone available in the case of an emergency however it is absolutely necessary for anyone who is taking high doses of opioids to have it in the home...Hopefully one will never have to use it but in the event an emergency dose happen one will be ready.
Please see the CDC video links below
If one is suspected of having an opioid overdose the naloxone can be vital.
Potential signs of an overdose: For a complete list see the link below
in and out of consciousness or complete loss of consciousness
Not responding to someone talking to them or one trying to rouse them
Change or difficulty in Breathing (slow and shallow, fluctuating, erratic, or has stopped entirely)
"Choking sounds, or a snore-like gurgling noise (sometimes called the “death rattle”)"
No strength in body- body is very limp
Change in color of Fingernails and lips (turn blue/purplish black)
Face is pale and/or clammy
Pulse (heartbeat) is slow, erratic, or not there at all
vomiting
If an overdose is suspected be prepared to use Narcan© and call 911
Please see the attached documentation from the CDC to help recognize if signs of overdose and what to do in case of an overdose.
Dispose of unused Opioid Medications:
To help and do your part in the Opioid Epidemic everyone should dispose of unused left over Opioids to help minimize access. Do not store Opioids in your home. Check with your pharmacy and local law enforcement for locations of drop boxes nearest to you.
**Please take note, my views are my own and are not associated or representative of my employer(s). This website and its associated platforms are for education purposes only and not medical advice. (If one wants to establish a relationship in which individual circumstances can be evaluated please send a message)
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