Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain

Abstract

The heightened interest in pain management is making the need for appropriate boundary setting within the clinician-patient relationship even more apparent. Unfortunately, it is impossible to determine before hand, with any degree of certainty, who will become problematic users of prescription medications. With this in mind, a parallel is drawn between the chronic pain management paradigm and our past experience with problems identifying the "at-risk" individuals from an infectious disease model. By recognizing the need to carefully assess all patients, in a biopsychosocial model, including past and present aberrant behaviors when they exist, and by applying careful and reasonably set limits in the clinician-patient relationship, it is possible to triage chronic pain patients into three categories according to risk. This article describes a "universal precautions" approach to the assessment and ongoing management of the chronic pain patient and offers a triage scheme for estimating risk that includes recommendations for management and referral. By taking a thorough and respectful approach to patient assessment and management within chronic pain treatment, stigma can be reduced, patient care improved, and overall risk contained.

Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain

“…Our study supports recommendations for a more standardized approach to opioid risk reduction. 11,13 A standardized approach could involve using screening tools to identify patients at increased risk for opioid misuse; 25,47-50 a treatment agreement that stipulates the necessity for regular office visits, restricted early refills, and urine drug testing; 51 and team-based care to track patients' visits, prescriptions, progress, and aberrant drug-taking behaviors. 52 Our research demonstrates the need for proactive approaches to this quality of care issue that has significant public health consequences.…”

“…Although strong evidence to support these recommendations is lacking, 11,12 experts endorse their role especially for patients at high risk of opioid misuse. [7][8][9]13 Several patient characteristics have been associated with an increased risk of opioid misuse in observational studies. Younger age has been consistently associated with opioid misuse, [14][15][16][17][18] with more than 70% of opioid overdose deaths occurring in individuals under age 45.…”

Nonmedical Use of Prescription Opioids: Motive and Ubiquity Issues

“…8,21,30,65,69,78 Also available in the extant literature are commentaries, review articles, and conceptual papers on nonmedical use of prescription opioids. 18,35,45,46,64 Articles such as these will give the reader a snapshot of what we have learned and will bring to light some pressing issues that remain to be explored for us to better grasp the problem. The purpose of this Focus Article is to discuss 2 issues that have previously been raised in one forum or another but to our knowledge have not been fully addressed in the peer-reviewed literature:…”

Opioid risk assessment in palliative medicine

“…Tis will give the provider an overview of the analgesic needs of the patient and may shed light on prior aberrant behavior. 23 However, as these topics are often sensitive in nature, they may not be clearly stated in medical documentation. A clinician must be adept at "reading between the lines" to obtain the full story.…”