Learning Objectives
By the end of this topic, the student should be able to:
- Recognize the importance of stepped care and its role in clinical practice.
- Recommend non-pharmacological interventions for managing pain such as lifestyle and psychological interventions.
- Recommend the use of non-opioid analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) for pain management.
- Recognize the need for adjuvant analgesics in treating different types of pain and as add-on therapy.
- Explain when the use of opioid analgesics is appropriate and the types of opioids used for differing levels of pain.
Key Concepts
- Stepped care is an individualized step-ladder approach to pain management where the lowest risk options are optimized first.
- Appropriate prescribing practices reduce the number of opioid prescriptions and opioid-related risks.
- There are numerous low-cost, low-risk, non-pharmacological interventions that can be recommended before an individual seeks pharmacological options. Many of these interventions have additional benefits such as improved sleep and mood.
- Non-opioid analgesics such as acetaminophen and NSAIDs should be optimized first before using opioid analgesics. They may have similar effectiveness in improving pain and function as opioid analgesics but with less risk.
- Adjuvant analgesics may be used on their own or in addition to other analgesics for relief of specific types of pain. Examples include antidepressants for neuropathic pain such as nortriptyline and muscle relaxants such as baclofen.
- Opioids may be considered as treatment for pain when an individual has exhausted the lower-risk options. Non-pharmacological interventions, non-opioid analgesics +/- adjuvant analgesics in addition to opioid therapy may improve pain relief.
Importance and Role of Stepped Care
A stepped care model for pain management is one in which the least intensive services are offered first. In other words, stepped care typically goes from interventions of low-risk (e.g., non-pharmacological) to interventions of high-risk (e.g., opioid analgesics)
- Appropriate prescribing practices, as a result of following a stepped care model, reduce the number of opioid prescriptions and subsequent opioid-related risks such as the development of problematic use.
An example of a step-wise approach to pain management is the World Health Organization (WHO) Pain Ladder, designed for cancer pain management.
WHO Pain Ladder for cancer pain management. An image of 3 steps. At the foot of the steps is the word ‘pain’. On the vertical edge of step 1: non-opioid +/- adjuvant. On the top of step 1: Pain persisting or increasing. Vertical edge of step 2: Opioid for mild to moderate pain +/- non-opioid +/- adjuvant. Top of step 2: Pain persisting or increasing. Vertical edge of step 3: Opioid for moderate to severe pain +/- non-opioid +/- adjuvant. Top of step 3: freedom from cancer pain.
World Health Organization. (1996). Cancer pain relief. [Image]. Retrieved from http://inctr-palliative-care-handbook.wikidot.com/who-pain-ladder and licensed under (CC BY-SA 3.0).
Summary of Recommendations for the Initiation of Opioids
Please review the summary of recommendations for the initiation of opioids from The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain (PDF).
Initiation and Dosing of Opioids in Patients with Chronic Noncancer Pain
Recommendation 1: When considering therapy for patients with chronic non-cancer pain
Strong Recommendation
We recommend optimization of non-opioid pharmacotherapy and non-pharmacological therapy, rather than a trial of opioids.
Recommendation 2: For patients with chronic noncancer pain, without current or past substance use disorder and without other active psychiatric disorders, who have persistent problematic pain despite optimized nonopioid therapy
Weak Recommendation
We suggest adding a trial of opioids rather than continued therapy without opioids.
By a trial of opioids, we mean initiation, titration, and monitoring of response, with discontinuation of opioids if important improvement in pain or function is not achieved. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses. The mental illnesses identified in studies as risk factors for adverse outcomes were generally anxiety and depression, including ICD-9 definitions, as well as “psychiatric diagnosis”, “mood disorder”, and post-traumatic stress disorder.
Recommendation 3: For patients with chronic noncancer pain with an active substance use disorder
Strong Recommendation AGAINST
We recommend against the use of opioids.
Clinicians should facilitate treatment of the underlying substance use disorders, if not yet addressed. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses.
Recommendation 4: For patients with chronic noncancer pain with an active psychiatric disorder whose nonopioid therapy has been optimized, and who have persistent problematic pain
Weak Recommendation
We suggest stabilizing the the psychiatric disorder before a trial of opioids is considered.
Recommendation 5: For patients with chronic noncancer pain with a history of substance use disorder, whose nonopioid therapy has been optimized, and who have persistent problematic pain
Weak Recommendation
We suggest continuing nonopioid therapy rather than a trial of opioids.
The studies that identified a history of substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses.
Recommendation 6: For patients with chronic noncancer pain who are beginning long term opioid therapy
Strong Recommendation
We recommend restricting the prescribed dose to less 90mg morphine equivalents daily rather than no upper limit or a higher limit on dosing.
Some patients may gain important benefit at a dose of more than 90mg morphine equivalents daily. Referral to a colleague for a second opinion regarding the possibility of increasing the dose to more than 90mg morphine equivalents daily may therefore be warranted in some individuals.
Recommendation 7: For patients with chronic noncancer pain who are beginning long term opioid therapy
Weak Recommendation
We suggest restricting the prescribed dose to less than 50mg morphine equivalents daily.
The weak recommendation to restrict the prescribed dose to less than 50mg morphine equivalents daily acknowledges that there are likely to be some patients who would be ready to accept the increased risks associated with a dose higher than 50mg in order to potentially achieve improved pain control.
Rotation and Tapering of Opioids, for Patients with Chronic Noncancer Pain
Recommendation 8: For patients with chronic noncancer pain who are currently using opioids, and have persistent problematic pain and/or problematic adverse effects
Weak Recommendation
We suggest tapering opioids to the lowest effective dose, potentially including discontinuation, rather than making no change in opioid therapy.
Some patients are likely to experience significant increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused and potentially abandoned in such patients.
Recommendation 9: For patients with chronic noncancer pain who are currently using 90mg morphine equivalents of opioids per day or more
Weak Recommendation
We suggest rotation to other opioids rather than keeping the opioid the same.
Rotation in such patients may be done in parallel with, and as a way of facilitating, dose reduction.
Recommendation 10: For patients with chronic noncancer pain who are using opioids and experiencing serious challenges in tapering
Strong Recommendation
We recommend a formal multidisciplinary program.
Recognizing the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction specialist, a psychiatrist, and a psychologist).
Canadian Medical Association Journal (CMAJ). (2017). The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain [Ebook] (pp. 4-6). Retrieved from http://nationalpaincentre.mcmaster.ca/guidelines.html and licensed under CC BY-NC-ND 4.0
A stepped approach to pain relief should be individualized for each person.
- It is important to ensure that the individual has given each step an adequate trial before deeming it ineffective and moving to the next step.
- An adequate trial for each step is determined based on both the dose and duration of use of a medication.
- Usually 2 to 4 weeks is the average trial period for each step, depending on the dose.
All health and social service providers can play an important role in setting expectations by frequently reassessing pain and providing ongoing education and reassurance to the individual.
For additional evidence-based information on non-pharmacological interventions and non-opioid analgesics, visit CADTH – Evidence on Pain Management and CADTH – Evidence on Opioids
Non-pharmacological Interventions
Many non-pharmacological interventions are low-cost with low-risk. Using these therapies can reduce the use of drugs and the risk of associated adverse effects.
- For acute pain, RICE can be applied.
- Examples of other non-pharmacological interventions for pain relief are listed below.
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Examples of Non-pharmacological Interventions
Lifestyle
- Smoking cessation,
- weight loss.
Psychological
- Contingency management,
- cognitive behavioural therapy,
- biofeedback,
- relaxation,
- imagery,
- psychotherapy,
- counselling,
- hypnosis,
- mindfulness,
- meditation,
- distraction and
- breath therapy.
Physical rehabilitation
- Stretches and exercises,
- yoga,
- gait and posture training,
- attention to ergonomics and body mechanics,
- thermotherapy,
- cryotherapy,
- counter-irritation,
- electroanalgesia (transcutaneous electric nerve stimulation),
- alternative treatments (acupuncture or therapeutic management), and
- laser.
Occupational
- Occupational therapy,
- work conditioning programs.
Complementary
- Acupuncture,
- herbal remedies,
- massage, and
- reflexology.
(Chang et al., 2017)
Fourleaflover/iStock (lifestyle, physical rehabilitation, complementary); Amanda Goehlert/iStock (psychological); Moto-rama/iStock (occupational)
Chronic pain self-management programs are available in many locations. They are education workshops that empower individuals to self-manage their chronic pain.
For example, see Self Management Ontario
Additional benefits of non-pharmacological interventions may include
- improved sleep
- improved mood
- reduced anxiety
- a sense of control
- improved coping ability
- increased quality of life
When non-pharmacological interventions alone are ineffective, non-opioid analgesics +/- adjuvant analgesics may be considered.
Non-opioid Analgesics
Non-opioid analgesics are preferred over opioids for most individuals with non-cancer pain. They may achieve similar effectiveness in improving pain and function relative to opioid analgesics with less risk of dependence, misuse, and overdose (Busse, 2017).
- Start at the lowest effective dose and titrate up (increase the dose) only as needed.
Examples of Non-opioid Analgesics
Acetaminophen
Acetaminophen is the first line for chronic mild pain, especially in older adults (American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons, 2009).
- Maximum daily dose is 4 grams per day from all sources.
- Acetaminophen is found in several over-the-counter products such as cough and cold medications.
- Client education is important to prevent liver toxicity.
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are more effective than acetaminophen for chronic inflammatory pain (Barkin et al., 2007).
- Examples include ibuprofen and naproxen.
- Generally, NSAIDs should be used for less than 2 weeks and avoided or used at lower doses for older adults because of increased side effects such as gastrointestinal bleeding and peptic ulcer disease.
Please review the table provided to see recommendations for initial dose and titration of nonopioid analgesics for persistent pain in older adults.
Adjuvant Analgesics
Adjuvant analgesics are primarily indicated for conditions other than pain; however, they have analgesic properties and can be used on their own or in addition to other analgesics.
Neuropathic pain relief
Antidepressants
Examples include:
- tricyclic antidepressants (TCAs)—nortriptyline, desipramine
- selective serotonin reuptake inhibitors (SSRIs)—paroxetine, fluoxetine
- selective noradrenalin reuptake inhibitors (SNRIs)—duloxetine, venlafaxine
Anticonvulsants
Examples include:
- pregabalin and
- gabapentin.
Muscle relaxants
Examples include:
- baclofen,
- methocarbamol, and
- cyclobenzaprine.
Topical analgesics
Topical analgesics provide localized pain relief in areas of application. They avoid the adverse effects associated with systemic use; however, they are usually less effective at providing pain relief.
They are a good option for older adults.
Examples include:
- topical NSAIDs,
- topical lidocaine, and
- capsaicin.
Intra-articular Glucocorticoids
These are injected directly into the joints and are commonly used for osteoarthritis pain.
Benzodiazepines
Benzodiazepines are not generally recommended as they can lead to misuse and have adverse effects with long-term use (e.g., falls/fractures, cognitive impairment). They may be used by some patients with pain complicated by an anxiety disorder.
Examples include:
- lorazepam,
- clonazepam, and
- diazepam.
Cannabis and Cannabinoids
The use of cannabinoids has shown modest effects in pain management of specific conditions; for all other conditions there is inadequate information to assess their effects.
Opioid Analgesics
When non-pharmacological interventions, non-opioid analgesics +/- adjuvant analgesics are ineffective, opioid analgesics may be considered.
Non-pharmacological interventions and non-opioid +/- adjuvant analgesics should not be discontinued if opioids are initiated.
However, drug interactions and polypharmacy should be considered.
- Polypharmacy is the concurrent and regular use of multiple medications (usually 5 or more medications daily).
Opioid analgesics require a prescription and close monitoring by the individual’s prescriber.
Exception:
- Some preparations with low-dose codeine (e.g., Tylenol #1) can be purchased without a prescription (excluding Manitoba). They are found behind the counter at pharmacies and require pharmacist intervention at the point of sale.
Mild to moderate pain
- The first line is codeine or tramadol.
- The second line is morphine, oxycodone, or hydromorphone.
Severe pain
- The first line is morphine, oxycodone, or hydromorphone.
- The second line is fentanyl.
- The third line is methadone.
All health and social service providers can play a role in educating individuals and their significant others on the safe use of opioid medications. For more information, see Module 6.
Stop and Think
Now that you have reviewed this content, consider the following:
What are some examples of non-pharmacological interventions that can be recommended to an individual experiencing chronic lower-back pain?
Refer to the stepped care approach and the considerations provided above.
Questions
References
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57(8), 1331. https://doi.org/10.1111/j.1532-5415.2009.02376.x
Barkin, R. L., Barkin, S. J., & Barkin, D. S. (2007). Pharmacotherapeutic management of pain with a focus directed at the geriatric patient. Rheumatic Diseases Clinics of North America, 33(1), 1. https://doi.org/10.1016/j.rdc.2006.12.001
Blott, S., & Regier, L. (2019). Pain: Overview of approach and treatment considerations. RxFiles. Saskatoon Health Region. https://www.rxfiles.ca
Busse, J. (2017). The 2017 Canadian guideline for opioids for chronic non-cancer pain. McMaster University. http://nationalpaincentre.mcmaster.ca/documents/Opioid%20GL%20for%20CMAJ_01may2017.pdf
Chang, F., Patel, T., Kluz, A., & Killeen, R. (2017). Module 3: Understanding and assessing chronic pain. In Opioid Education Partnership. School of Pharmacy, University of Waterloo.
Crawley, A., & Regier, L. (2019). Prescribing opioids safely in chronic pain. RxFiles. Saskatoon Health Region. https://www.rxfiles.ca
Galicia-Castillo, M., & Weiner, D. K. (2020). Treatment of persistent pain in older adults. In T. Post (Ed.), UpToDate. https://www.uptodate.com/contents/treatment-of-persistent-pain-in-older-adults
National Pharmaceutical Council. (2001). Pain: Current understanding of assessment, management, and treatments. https://www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf
Rosenquist, E. W. K. (2019). Overview of the treatment of chronic non-cancer pain. In T. Post (Ed.), UpToDate. https://www.uptodate.com
RxFiles. (n.d.). Pain management in older adults. GeriRxFiles. Saskatoon Health Region. https://www.rxfiles.ca.
World Health Organization Staff & World Health Organization. (1996). Cancer pain relief: With a guide to opioid availability.