Nebraska Pain Management Guidance Document A Provider and Community Resource Developed by the Department of Health and Human Services in collaboration with an expert advisory task force, actively practicing providers, and senior state officials. Written for Clinicians who are helping people live better lives. www.dhhs.ne.gov/PDMP 1st Edition, October 2017 “Helping People Live Better Lives” | pg. 1 “Helping People Live Better Lives” | pg. 2 Table of Contents INTRODUCTION ............................................................................................................. 7 The Nebraska Pain Management Task Force .......................................................................... 7 Nebraska Pain Management Guidelines Authors and Contributors ......................................... 8 CDC Guidelines ....................................................................................................................... 8 Axioms and Pain Treatment .................................................................................................. 10 Team Approach to Pain Management ................................................................................... 12 How to Use this Guidance Document .................................................................................... 12 Morphine Milligram Equivalent (MME) ................................................................................... 13 Risk Stratification ................................................................................................................... 14 THE ART OF DIFFICULT CONVERSATIONS ............................................................. 16 Value Identification ................................................................................................................ 16 Realistic Expectations ........................................................................................................... 16 Willingness to Feel Uncomfortable ........................................................................................ 17 Relationship as a Resource ................................................................................................... 17 Belief and Confidence ........................................................................................................... 17 Motivational Interviewing ....................................................................................................... 17 Resources ............................................................................................................................. 18 TREATING ACUTE PAIN (0-7 Days Following Trauma or Surgery) ........................ 19 Assessment ........................................................................................................................... 19 Non-Opioid Treatment ........................................................................................................... 19 NSAID Treatment .................................................................................................................. 19 Opioid Treatment ................................................................................................................... 20 Patient Instructions ................................................................................................................ 21 Tools ..................................................................................................................................... 21 Acute Pain Flow Sheet .......................................................................................................... 22 TREATING CHRONIC PAIN (Pain Lasting More Than Three Months) ..................... 23 Categorization of Chronic Pain Patients ................................................................................ 23 Nociceptive and Neuropathic Pain ......................................................................................... 24 Central Pain or Central Sensitization (CS)/Hyperalgesia ....................................................... 24 Assessment for Chronic Non-Cancer Pain............................................................................. 25 Opioid Treatment ................................................................................................................... 25 NSAID Treatment .................................................................................................................. 27 Non-Opioid Treatment ........................................................................................................... 27 “Helping People Live Better Lives” | pg. 3 Patient Instructions ................................................................................................................ 27 Tapering ................................................................................................................................ 27 Additional Concerns .............................................................................................................. 28 Tools ..................................................................................................................................... 29 Chronic Pain Flow Sheet ....................................................................................................... 30 NON-OPIOID OPTIONS ............................................................................................... 31 Non-Opioid Treatment Options .............................................................................................. 31 Behavioral Treatment Options ............................................................................................... 32 SPECIALTY CARE FOR TREATING CHRONIC PAIN ................................................ 34 Patient Selection for Pain Specialty Care .............................................................................. 34 Screening and Evaluation ...................................................................................................... 34 Oversight ............................................................................................................................... 35 Pain Specialty ........................................................................................................................ 35 Services ................................................................................................................................ 35 Long-Term Management Goals ............................................................................................. 36 TRAUMA, PTSD & CHRONIC PAIN ............................................................................ 37 Trauma and Chronic Pain ...................................................................................................... 37 Screening and Referral Overview .......................................................................................... 37 Treatment Of Trauma ............................................................................................................ 38 What Can Healthcare Providers Do ....................................................................................... 38 Tools ..................................................................................................................................... 38 TREATING PAIN IN CHILDREN AND ADOLESCENTS .............................................. 39 Assessment ........................................................................................................................... 39 Non-Opioid Treatment ........................................................................................................... 39 Opioid Treatment ................................................................................................................... 39 Tools for Adolescents ............................................................................................................ 40 PAIN CONTROL IN THE ELDERLY AND INDIVIDUALS WITH DEMENTIA .............. 41 Chronic Pain in the Elderly Population ................................................................................... 41 Evaluation of the Elderly Patient ............................................................................................ 41 Goals of Treatment ................................................................................................................ 41 Non-Pharmaceutical Approach .............................................................................................. 42 Pharmaceutical Approach ...................................................................................................... 42 Pain Treatment in Patients with Dementia ............................................................................. 44 PAIN CONTROL FOR CANCER AND PALLIATIVE CARE ........................................ 45 What Is Palliative Care .......................................................................................................... 45 Why is Palliative Care Important ............................................................................................ 45 Palliative Care Approaches ................................................................................................... 46 “Helping People Live Better Lives” | pg. 4 OPIOID USE DURING PREGNANCY .......................................................................... 47 MANAGING PATIENTS IN THE EMERGENCY DEPARTMENT ................................. 48 RECOMMENDED OPIOID POLICY FOR DENTISTS