PAIN MANAGEMENT OF INMATES Federal Bureau of Prisons Clinical Guidance JUNE 2018 Federal Bureau of Prisons (BOP) Clinical Guidance is made available to the public for informational purposes only. The BOP does not warrant this guidance for any other purpose, and assumes no responsibility for any injury or damage resulting from the reliance thereof. Proper medical practice necessitates that all cases are evaluated on an individual basis and that treatment decisions are patient- specific. Consult the BOP Health Management Resources Web page to determine the date of the most recent update to this document: http://www.bop.gov/resources/health_care_mngmt.jsp Federal Bureau of Prisons Pain Management of Inmates Clinical Guidance June 2018 TABLE OF CONTENTS 1. PURPOSE OF THIS GUIDANCE.................................................................................................................. 1 2. INTRODUCTION TO PAIN MANAGEMENT IN THE BOP .................................................................................. 1 The Prevalence of Chronic Pain ........................................................................................................ 1 General Principles of Pain Management in the BOP .......................................................................... 2 Multiple Dimensions of Pain Management ................................................................................... 2 Interdisciplinary Pain Rehabilitation (IPR) .................................................................................... 2 Roles of the MTT and the PMT.................................................................................................... 2 3. THE BODY’S PAIN-RESPONSE MECHANISMS ............................................................................................ 2 Mechanisms of Acute Pain ................................................................................................................ 3 Mechanisms of Chronic Pain ............................................................................................................. 3 Peripheral Sensitization............................................................................................................... 3 Central Neuroreceptor Sensitization ............................................................................................ 3 4. TYPES OF PAIN ...................................................................................................................................... 4 Acute Pain......................................................................................................................................... 4 Chronic Pain ..................................................................................................................................... 4 TABLE 1. PAIN MANAGEMENT: ACUTE VS. CHRONIC ......................................................................... 4 Nociceptive Pain ............................................................................................................................... 5 TABLE 2. CLASSIFICATION OF NOCICEPTIVE PAIN ............................................................................ 5 Neuropathic Pain ............................................................................................................................... 5 Psychogenic Pain .............................................................................................................................. 5 Idiopathic Pain................................................................................................................................... 6 Hyperalgesia ..................................................................................................................................... 6 Opioid-Induced Hyperalgesia............................................................................................................. 6 5. TOLERANCE, PHYSICAL DEPENDENCE, AND ADDICTION ............................................................................. 6 Tolerance .......................................................................................................................................... 6 Physical Dependence ........................................................................................................................ 7 Addiction ........................................................................................................................................... 7 Pseudoaddiction ................................................................................................................................ 7 Substance Abuse .............................................................................................................................. 8 6. TEAM APPROACH TO CHRONIC PAIN MANAGEMENT IN THE BOP ................................................................ 8 Two Tiers of Pain Management Resources ................................................................................. 8 Tier 1: Local Pain Management ........................................................................................................ 9 Medical Treatment Team (MTT) .................................................................................................. 9 Multidisciplinary Pain Management Team (PMT) ......................................................................... 9 TABLE 3. COMPOSITION OF THE PMT ........................................................................................... 10 Tier 2: Outside Pain Specialist ........................................................................................................ 10 7. FOCUS OF CLINICAL VISITS ................................................................................................................... 11 8. INITIAL PAIN EVALUATION AND DOCUMENTATION .................................................................................... 12 i Federal Bureau of Prisons Pain Management of Inmates Clinical Guidance June 2018 9. PAIN MANAGEMENT CARE PLANS ......................................................................................................... 14 FIGURE 1. THE PAIN CYCLE ......................................................................................................... 14 Developing and Administering the Plan ........................................................................................... 15 Medication Considerations .............................................................................................................. 15 Nonopioid Pain Meds ................................................................................................................ 15 Considerations in Using Opioid Pain Meds for Chronic Pain ...................................................... 15 Issues Related to Methadone .................................................................................................... 16 Contraindications to Using Opioids ............................................................................................ 17 TABLE 4. CONTRAINDICATIONS TO OPIOID THERAPY ....................................................................... 17 Documenting the Decision to Prescribe Opioid Therapy................................................................... 18 Management of Opioid “Allergy” ...................................................................................................... 19 TABLE 5. OPIOID “ALLERGY” SYMPTOMS TO CONSIDER ................................................................... 20 TABLE 6. MANAGEMENT OPTIONS FOR OPIOID PSEUDOALLERGY ..................................................... 20 TABLE 7. MANAGEMENT OPTIONS FOR TRUE OPIOID ALLERGY ........................................................ 20 Opioid Exit Strategy ......................................................................................................................... 21 Opioid Overdose ............................................................................................................................. 21 10. ONGOING MONITORING AND MANAGEMENT .......................................................................................... 22 Managing Acute Pain ...................................................................................................................... 22 Managing Chronic Pain ................................................................................................................... 22 Pain Reassessment Visits ......................................................................................................... 22 Other Recommendations Regarding Reassessment and Monitoring .......................................... 22 Managing Cancer Pain .................................................................................................................... 23 11. DENTAL PAIN MANAGEMENT ............................................................................................................... 24 Types of Dental and Orofacial Pain ................................................................................................. 24 Nonopioid Analgesics for Dental Pain .............................................................................................. 24 Opioid Analgesics as Adjuncts in Treating Dental Pain .................................................................... 25 12. COMMUNICATION STRATEGIES ...........................................................................................................