Pain Management and the Groundhog Day Phenomenon
LAS VEGAS — Although policies, procedures, and practices related to treating chronic pain are being discussed at national and international levels, there are often challenges to implementing widespread change.
Kevin Zacharoff, MD, of PainEDU.org, discussed some of these hurdles, and ways to get over them, during his session, “The Groundhog Day Phenomenon.” Named after the popular film in which the main character relives the same day over and over, Dr. Zacharoff said that the inspiration for his session's title came about because he believes the medical community seems to be unable to make progress in pain policy and procedure; in essence, reliving the same day.
“From healthcare system to healthcare system and practice to practice I have spoken with, it seems that everyone who thinks that the time has come for a ‘pain policy and procedure set' feels as if they've discovered this on their own, when in actuality it has been promoted in many different ways and forms at least over the past 15 to 20 years or more,” said Dr. Zacharoff. “This ‘reinventing the wheel' phenomenon, despite a plethora of writings, guidelines, national meetings, and debates, certainly seems like a ‘Groundhog Day' phenomenon to me and doesn't seem to be changing.”
Fortunately, Dr. Zacharoff noted that there is a growing body of evidence that has helped to clarify “the misunderstanding of addiction, physical dependence, and analgesic tolerance; the misconception that chronic opioid therapy inevitably causes personality changes … and the lack of information on the correct use of opioid analgesics with regard to titration and management of related side effects.”1
Dr. Zacharoff offered some of his own clinical perspectives on this growing body of evidence. He said in addition to arriving at a diagnosis for the cause of a patient's pain, it is important to “address any comorbid conditions, including probable substance use disorders and other psychiatric illness.”
Discussing psychiatric illness, Dr. Zacharoff explained that a complete psychological assessment, including personal and family history of substance use, is integral to treating patients with chronic pain. He urged clinicians to discuss patient-centered urine drug testing with all patients. A psychological assessment should also include risk, he explained.
“A sensitive and respectful assessment of risk should be done with available tools and should not be seen in any way as diminishing a patient's complaint of pain or reliability,” Dr. Zacharoff said.
Obtaining informed consent is also important, Dr. Zacharoff noted, adding that it is imperative that clinicians “educate the patient about the proposed treatment plan with opioids including: anticipated benefits, foreseeable risks, and concerns at a level appropriate to the individual patient.”
Dr. Zacharoff explained that a treatment agreement is also key. Such agreements should incorporate the expectations and obligations of both the patient and the treating practitioner.
Also integral to treating the patient with chronic pain is a pre- and postintervention assessment.
“Initiation of opioid therapy for patients in this setting should be considered a ‘trial' of therapy by both the clinician and patient,” Dr. Zacharoff said. “Without prior assessment of pain level and function, it would be impossible to measure progress.”
He said it is important to consider that opioids “may or may not be the first treatment of choice, and will most likely be used with other adjunctive medications.”
Discussing alternatives to opioids, Dr. Zacharoff cited data that concluded: “Methadone is characterized by complicated and variable pharmacokinetics and pharmacodynamics and should be initiated and titrated cautiously by clinicians familiar with its use and risks.” 2
Reassessment of Pain and Function
In addition to preassessment of pain and making a judicious decision regarding the use of opioids, Dr. Zacharoff explained that it is important to regularly assess the patient for either continuing or discontinuing therapy. He called this assessment the “Four As” of pain medicine: analgesia, activity, adverse effects, and aberrant behavior.
“Clinicians should reassess patients on chronic opioid therapy periodically and as warranted by changing circumstances,” Dr. Zacharoff said. He added that monitoring should include documentation of the pain intensity, the patient's level of function, assessment of progress, adverse events, and adherence.
“Refills should only be provided with conclusion that the therapeutic index is moving in the right direction,” he cautioned.
Discussing high-risk patients, Dr. Zacharoff explained, “Clinicians may consider chronic opioid therapy for patients with chronic noncancer pain and a history of drug abuse, psychiatric issues, or serious aberrant drug related behaviors only if they are able to implement more frequent and stringent monitoring parameters.” He also urged consultation with mental health, addiction, and/or pain specialists.
In all patients, Dr. Zacharoff explained that thorough risk/benefit analysis is vital to treatment success, as are rotating opioid agents and discontinuation of treatment when appropriate. He encouraged clinicians in attendance to consider adjunctive medications and therapies, and to monitor breakthrough pain treatment medications as well.
Importance of Documentation
Documenting is in the best interest of both patients and clinicians, Dr. Zacharoff said, noting that “thorough documentation can reduce medicolegal exposure and risk of regulatory sanction.”
The rule of thumb to remember, Dr. Zacharoff said, is “if you do not document it, it did not happen.”
“Reproducible and clinically relevant and implementable information that resonates with clinicians providing treatment for people with chronic pain needs to happen so people can share this information with each other and become vectors for knowledge,” concluded Dr. Zacharoff.
- Pappagallo M, Heinberg LJ. Ethical issues in the management of chronic nonmalignant pain. Semin Neurol. 1997;17(3):203-211.
- Chou R. 2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: what are the key messages for clinical practice? Pol Arch Med Wewn. 2009;119(7-8):469-477.