When in Doubt, Refer, Do Not Treat

LAS VEGAS—There are several common misconceptions about how nurse practitioners should handle pain treatment and referral, said Brett B. Snodgrass, MSN, APRN, and FNP-C, of St. Francis Hospital in Bartlett, Tennessee to PAINWeek attendees.

These include the belief that the NP must continue prescribing a medication that a patient claims to be on, at their initial visit. Other common misconceptions are that if one has a DEA number, then one must prescribe what a supervisor tells one to prescribe, or that “you must treat if a patient refuses a referral,” she added.

In reality, NPs have broad discretion about whether to treat or refer a patient for pain treatment. Recurring ER visits for chronic pain management, frequently losing prescriptions, concurrent use of illicit drugs, or stealing or borrowing medications are all red flags for opioid abuse, she cautioned.

Patients frequently pressure clinicians for prescriptions, but a NP's decision to treat or refer should be based on consistent considerations and processes, Snodgrass said. She recommends referring within your practice if possible, before referring patients to outside experts—and to exhaust all non-opioid alternatives before considering an opiate prescription. “Only treat what you are comfortable treating,” she advised.

“Only treat with products you are comfortable treating with (and) consider the risk stratification.” “Make certain to have a definitive diagnosis,” she added. If you do not have one, then refer the patient. Referrals for pain management, even if referring patients to a colleague within your practice, helps to justify appropriate doses, especially when using higher doses of opiates for hospice or palliative care; another provider agrees with a treatment plan or “another set of eyes may uncover something else,” she said.

Risk assessment and stratification tools should be used when a patient is considered for long-term opioid therapy. The five-item Opioid Risk Tool (ORT) and 26-item Pain Medication Questionnaire (PMQ) can be filled out by patients, for example. Clinicians can complete the seven-item Diagnosis, Intractability, Risk & Efficacy (DIRE) scoring instrument or 40-item Prescription Drug Use Questionnaire (PDUQ) to conduct risk assessments, she explained.

The “four pillars” of oral pain therapy are antiinflammatories, mood modulators, anticonvulsants and opiates.But exhausting nonpharmaceutical interventions before prescribing or referring patients for opioid therapy, is very important. She listed several examples: physical therapy, massage, yoga, walking, music and art therapy, transcutaneous electrical nerve stimulation (TENS).

Rules and regulations about referral of pain management patients can vary between states, so it's important to familiarize oneself with those. Many states have promulgated chronic pain management and/or opioid prescribing guidelines.

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