Our country is currently facing an opioid overdose epidemic. This is posing a serious risk on the life of many people. The Centers for Disease Control and Prevention (CDC) has taken the initiative to educate clinicians on the risks of prescribing opioids for the treatment of chronic pain as well as other alternatives available for the management of pain. For this paper, I have selected the module “CDD Recommendations for Non-opioids Treatments in the Management of Chronic Pain”. These recommendations are exceptionally useful for clinicians to understand that there are other available options for the management of chronic pain. Health authorities are alarmed with the increase morbidity and mortality associated with opioid use. Overprescribing opioids increased the opioid addiction crisis as well as the increased number of deaths by overdose.
There is not sufficient evidence to conclude if the long term use of opioids has any positive impact in the quality of life of people with pain. There are many non-opioid medications available to manage chronic pain with less harmful side effects. Current opioid treatments available for the management of chronic pain possess serious risks of addiction, overdose death, abuse and dependency. As the CDC stated opioids are not the first-line treatment for chronic pain. At this time the CDC recommendations for the management of chronic pain is the use of non-pharmacological therapy and non-opioid therapy. The CDC recommends clinicians to prescribe opioids only if the patient’s benefits are anticipated to outweigh the risks. The CDC recommends that if opioids are to be prescribed they need to be in combination of non-opioid medications and non-pharmacological approaches.
The use of non-opioid medications includes Acetaminophen, NSAIDs, and COX-2 inhibitors. It has also been useful the use of anticonvulsants and antidepressants. There are other effective ways to manage chronic pain; non-pharmacological approaches that can be successfully used include exercise therapy, and cognitive behavioral therapy (CBT). The use of CBT helps patients to build useful behavioral techniques; it also assists patients to change cognitive process that can aggravate their pain. The education of patients to practice relaxation techniques is vital as well as discussing the benefits of educational community programs. It is critical to keep in mind that sometimes patients may not have the means to access to non-pharmacological treatments. Clinicians should take in consideration low cost options to integrate exercise, like brisk walking in public spaces, public recreation for group exercise. The use of non-pharmacological approaches had sustained improvements in pain and should be encouraged.
As clinicians we should encourage our patients to actively participate in the plan of care. It is also vital to understand and address the results of pain as well as the impact on the patient’s quality of life. Patients should be informed about the benefits of exercise therapy. It has been proven that exercise therapy can reduce pain. Guidelines strongly recommend for patients with osteoarthritis, back pain, fibromyalgia to practice aerobic, aquatic, and resistance exercise.
The CDC states that Acetaminophen is the first line treatment for osteoarthritis and low back. It is important to take in consideration that Acetaminophen is contraindicated in patients with liver failure. It remains vital to screen patients for alcohol abuse history. NSAID and cyclooxygenase 2 (COX-2) inhibitors are also the first line treatment for Osteoarthritis and low back pain. With the use of NSAIDs and COX-2 something to take in consideration is the increased risks for gastrointestinal bleeding, fluid retention and cardiovascular risks. Clinicians always should weigh the risks and benefits of the use of NSAIDs when treating older adults. Special consideration should be taken in patients with renal problems, high blood pressure, heart failure, peptic ulcers and cardiovascular diseases. For neuropathic pain and Fibromyalgia the use of selected antidepressants like Tricyclics and SNRIs are highly effective. It is also imperative to take in consideration that the use of these drugs can cause drowsiness, and should be taken before bed; they are also contraindicated in serious cardiac diseases. Patients initiating treatment with Tricyclics should begin treatment with low doses of medicine, and increase of the dose slowly as necessary. Another option to keep in mind is the use of selected anticonvulsants; they can be useful in the management of post-herpetic neuralgia, diabetic neuropathy and fibromyalgia. Monitor CBC and LFTs periodically. Intraarticular steroid injections can help patients with Rheumatoid Arthritis (RA) as well as patients with Osteoarthritis (OA). For injuries to the rotator cuff, steroid injections can also be useful to manage pain.
The CDC reinforces the importance of evaluating patients accordingly to select the most adequate therapy. Obtaining an accurate history, the characteristics of pain, aggravating factors, physical exam, and presence of neurologic problems can be extremely helpful to select the right treatment. Clinicians always have the option to refer patients to a pain specialist. The use of physical therapy (PT) and occupational therapy (OT) can be of tremendous value in the management of pain. There are also surgical interventions to relieve compressive pain. The education of blood sugar control in diabetics is vital to prevent the progression of diabetic neuropathy.
It is imperative to understand that clinicians should only use medications after determining that the benefits of the treatment outweigh the risks. There are some other risks to take in consideration when prescribing pharmacologic therapy; for instance the risks for falls when using medications that cause drowsiness or sedation like tricyclics, anticonvulsants or opioids. Recommendations are to prescribe topical NSAIDs above oral NSAIDs for localized OA in patients older than 75 years of age.
In conclusion, there are continuing efforts by the government to improve clinician’s training in pain management, as well as the implementation of drug monitoring programs. There is also an expanding access to effective opioid agonist and antagonist drugs for the prevention of overdose. As previously discussed in this paper, opioids are not indicated for the management of chronic pain. There are different alternatives for the management of chronic pain. These alternatives include non-pharmacological approaches as well as non-opioid medications.
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