Challenges of Managing Chronic Pain with Opioids

Published

Managing patients with chronic pain is a constant challenge for physicians. We frequently receive questions from clinicians about handling these complex situations. Questions about prescribing opioids include when to use opioids and how to monitor their use. In this episode of Curbside Consults, we explore these topics, examine case scenarios that highlight worrisome opioid use, and discuss how to manage the patient visit when there are unexpected findings on the state prescription drug monitoring program or urine drug tests. We offer tips on how to manage your feelings and set realistic expectations. This discussion is based on the NEJM Knowledge+ module on Pain Management and Opioids, available free at knowledgeplus.nejm.org.

0:00 – 1:13 - Introduction preamble
0:57 - Introduction of panelists
1:12 - What is the evidence for using opioids for management of chronic pain?
2:47 - Do opioids analgesics have a role in treating chronic pain? An approach to prescribing opioids and the importance of a multimodal approach to pain management
3:37 - How to respond to skeptical clinicians who would rather see a patient in pain than lose a patient to opioid misuse
4:31 - Tips and challenges for the clinician tasked with managing chronic pain, including how to manage your feelings and set realistic expectations
6:22 - Differences between treating chronic pain and treating other chronic conditions
6:52 - Measuring benefits and harm
8:08 - A typical approach to a patient presenting with chronic pain: The multidisciplinary approach
9:02 – The follow-up visit and use of the PEG scale
9:41 - SMART goals for measuring improvement in function
11:22 - Objective tools for monitoring patients on opioids: Dealing with unexpected results and establishing focused visits
13:14 - How to deal with patients who admit to “breaking contract” opioids in a way that differs from the prescription agreement
14:50 - Dealing with breach of trust and patients who may lie
16:24 - Dealing with unexpected findings on routine testing
17:41 - Maintaining compassion
19:05 - Take away points
21:30 - Outro

The information in this podcast is based on the NEJM Knowledge+ module on Pain Management and Opioids.

- For more information about the free NEJM Knowledge+ Pain Management and Opioids module, click here.
- For more information about Scope of Pain, click here.

The Curbside Consults series complements the foundational information in Rotation Prep by taking a deep dive into key clinical topics with expert clinicians and educators. These podcasts explore and critique the evidence behind clinical practice and break down statistical concepts for the busy clinical trainee.

Dr. Daniel Alford is Professor of Medicine, Associate Dean of Continuing Medical Education and Director of the Safer and Competent Opioid Prescribing Education or SCOPE of Pain program at Boston University School of Medicine. He is on staff in the Section of General Internal Medicine and director of the Clinical Addiction Research and Education Unit at Boston Medical Center. His clinical, educational and research interests focus on managing opioid use disorders and safer opioid prescribing for pain.

Dr. O.P. Hamnvik is the Education Editor for NEJM Group. He collaborated with Dr. Daniel Alford on the creation of the module on Pain Management and Opioids for NEJM Knowledge+.