Health Care Guideline Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management How to Cite this Document Hooten M, Thorson D, Bianco J, Bonte B, Clavel Jr A, Hora J, Johnson C, Kirksson E, Noonan MP, Reznikoff C, Schweim K, Wainio J, Walker N. Institute for Clinical Systems Improvement. Pain: Assess- ment, Non-Opioid Treatment Approaches and Opioid Management. Updated August 2017. ICSI Members, Sponsors and organizations delivering care within Minnesota borders, may use ICSI documents in the following ways: • ICSI Health Care Guidelines and related products (hereinafter “Guidelines”) may be used and distributed by ICSI Member and Sponsor organizations as well as organizations delivering care within Minnesota borders. 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All other copyright rights for ICSI Health Care Guidelines are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any use, adaptations, revisions or modifications made to ICSI Health Care Guidelines by the user or others. www.icsi.org Copyright © 2017 by Institute for Clinical Systems Improvement Health Care Guideline: Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Pain Assessment Algorithm Eighth Edition August 2017 Text in blue in this algorithm Patient presents with indicates a linked corresponding pain complaint/concern annotation. Assessment 1 Assess quality-of-life, function and pain 2 Determine the pain 3 Dental /orofacial pain generator diagnosis and treatment • Treat acute dental with 3 NSAIDs and yes acetaminophen Dental? • Refer to dental provider ASAP no • Avoid opioid 4 medication Assess physical and behavioral health comorbidities • Consider screening for substance use disorder and other comorbidities • Consider specialty referral 5 Determine patient barriers Shared 6 decision-making Patient engagement • Use shared decision-making and motivational interviewing to set achievable goals and expectations • Review risks and benefits of treatment options, reach agreement and get informed consent as needed See Pain Treatment Plan algorithm Return to Table of Contents www.icsi.org Copyright © 2017 by Institute for Clinical Systems Improvement 1 Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Eighth Edition/August 2017 Pain Treatment Plan Algorithm Text in blue in this algorithm indicates a linked corresponding 7 annotation. Develop pain treatment plan Shared decision-making 8 9 10 11 12 Complementary Physical Psychotherapy Interventional Pharmacologic and integrative rehabilitation strategies treatment treatment medicine modalities Shared decision-making Consider opioids if: • Other treatments are not sufficient • Emergent pain relief is indicated 14 Coordination of Care and Follow-Up 13 • Proactive management of condition and Opioid management collaborative care referrals (see Acute Opioid • Team-based patient care Treatment algorithm) • Follow-up and communication plan • Periodic reassessment of goals and function Goals met? Is care plan Return to patient • Function no no implemented as engagement to re-establish • Comfort planned? treatment goals • Barriers yes yes Ongoing pain management as needed Is diagnosis no Return to pain assessment correct? yes Shared decision-making • Reassess treatment plan • Consider multidisciplinary team referral, and/or a pain medicine specialist Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 2 Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Eighth Edition/August 2017 Acute Opioid Treatment Algorithm 13 Text in blue in this algorithm 13.2 Opioid indicates a linked corresponding Risk assessment management annotation. Consider ABCDPQRS: • Alcohol use • Benzodiazepines and other 13.1 drug use Return to Pain • Clearance and metabolism of no Have non-opioid drug Treatment Plan approaches been • Delirium, dementia and falls algorithm considered? risk yes • Psychiatric comorbidities • Query the prescription 13.2 Risk Assessment monitoring program Consider • Respiratory insufficiency and ABCDPQRS sleep apnea • Safe driving, work, storage and disposal Is patient: 13.3 • Pregnant, lactating or woman of yes See Special childbearing age Populations section • Geriatric • Pediatric? no Shared decision-making Does potential no benefit of opioid outweigh potential risk? yes Shared 13.4 decision-making Prescriber responsibility with opioid prescription, not limited to: • Patient education • Safe use, storage and disposal • Shared decision-making • Consider patient provider agreement • Consider offering naloxone 13.5 Acute or acute on chronic pain 13.6 The first opioid prescription for acute pain Avoid opioid use for chronic pain. should be the lowest possible effective For patients currently on opioids see strength of a short-acting opioid, not to Consideration of Continuing Opioid exceed 100 MME total. Patients should be Treatment for Pain algorithm. instructed that three days or less will often be sufficient. 14 Return to “Coordination of Care and Follow-Up” on Pain Treatment Pain algorithm Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 3 Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Eighth Edition/August 2017 Consideration for Continuing Opioid Treatment Algorithm Consideration of Text in blue in this algorithm continuing opioid indicates a linked corresponding treatment for pain annotation. 13.2 13.1 Risk assessment no Have non-opioid Consider ABCDPQRS: approaches been • Alcohol use considered? • Benzodiazepines and other drug use Return to Pain Treatment Plan yes • Clearance and metabolism of algorithm, modalities and Shared drug non-opioid pharmacology decision-making • Delirium, dementia and falls no Is opioid still risk effective? • Psychiatric comorbidities • Query the prescription monitoring program yes • Respiratory insufficiency and 13.2 sleep apnea Risk Assessment • Safe driving, work, storage Consider and disposal ABCDPQRS Is patient: • Pregnant, lactating or 13.3 woman of yes See Special childbearing age Populations section • Geriatric • Pediatric? no Shared decision-making Does potential no benefit of opioid outweigh potential risk? yes 13.4 Prescriber responsibility with opioid prescription, not limited to: • Patient education • Safe use, storage and disposal • Shared decision-making • Consider patient provider agreement 13.7 MME: Morphine Ongoing treatment of pain with opioids Opioid pharmacology milligram equivalents Manage dose limits to • MME conversion factors SUD: Substance use < 100 MME/day or < 50 MME/day with • Opioid rotation disorder SUD or benzodiazepine use 13.8 Monitoring considerations for opioid use: • Patient provider agreement • Monitor patient at least monthly until stable, then every 3 months • Query prescription monitoring program twice a year • Urine drug screening once a year • Have referral source for psychiatry, physical therapy, substance use disorder treatment and pain medicine 13.9 Return to If opioid use disorder is suspected “Coordination of Care consider referral to addiction medicine and Follow-Up” on specialist Pain Treatment Plan 13.10 algorithm Offer discontinuation of opioids or taper Return to Table of Contents at intervals of six months www.icsi.org Institute for Clinical Systems Improvement 4 Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Eighth Edition/August 2017 Table of Contents Work Group Leaders Algorithms and Annotations ........................................................................................ 1-80 Michael Hooten, MD Algorithm – Pain Assessment ...............................................................................................1 Anesthesiology, Mayo Clinic David Thorson, MD Algorithm – Pain Treatment Plan .........................................................................................2 Sports Medicine, Entira Family Algorithm – Acute Opioid Treatment ...................................................................................3 Clinics Algorithm – Consideration for Contuining Opioid Treatment .............................................4 Work Group Members Evidence Grading ............................................................................................................. 7-8 Allina Medical Clinic Justin Hora, PharmD Recommendations Table ................................................................................................ 9-16 Specialty Foreword Emergency Physicians, PA Introduction ............................................................................................................