Chronic Opioid Clinical Management Guidelines for Wisconsin Worker’s Compensation Patient Care
Emerging medical evidence shows that the previously pursued practice patterns of using higher dose chronic opioids rarely results in sustained improvements in pain control and function, but has resulted in increased addiction and death nationally over the last 10 years. These Clinical guidelines will assist you in managing your patients with chronic pain…
The following steps for patients who require chronic opioid treatment for a worker’s compensation injury should be followed:
1. The Pain Generator Must be Adequately Evaluated
-A clear etiology and diagnosis of the pain should be identified and documented at every visit.
“Chronic Back/Neck Pain” is a symptom, not a diagnosis.
-Not all pain conditions are opioid responsive; therefore, not all diagnoses that cause pain are appropriate for chronic opioids. Chronic headaches and fibromyalgia would be examples of diagnoses that are not appropriate to be treated with chronic opioids.
-If you are not able to identify (a) specific medical diagnosis(es) responsible for the patient’s pain, then consider that the patient has not been properly worked up for a pain generator or the patient does not have a medical diagnosis that warrants the use of chronic opioid therapy…
-Opioid therapy truly needs to be considered a last resort…
3. Patient Criteria for Long Term Opioid Therapy?
-Patients must have persistent (i.e. daily) moderate to severe pain (pain 5 and over on the
10 point scale).
-Patients must have daily, describable functional limitations due to pain.
-Identifiable medical diagnosis, known to be appropriate for chronic opioids therapy (i.e. the
pain generator/Diagnosis is not chronic pain syndrome, pain, or headache etc).
-Minimum risk profile as identified by standard screening (SOAPP recommended)…
For patients with high SOAPP scores and unclear clinical conditions, consideration can be given to not offering chronic opioid therapy because the risks outweigh benefits. If the patient is already on them, they could be appropriately discontinued…
Chronic opioid therapy is a goal-directed therapy, and goals must be stated so that if they are not met, the medications can be appropriately discontinued. Goals of chronic opioid therapy include:
–Sustained pain reduction (at least 30% as compared to pre-treatment).
-Sustained functional improvement.
-Strict compliance with the opioid treatment agreement
Consider explaining to patients on higher doses of opioids that newer clinical evidence demonstrates that lower doses of opioids are just as effective in maintaining sustained functional improvements and pain reductions…
Where’s this evidence? Sounds like something PFROP made up.
It is highly unusual for a patient who is compliant with taking chronic opioids to not have constipation; therefore, all patients should be on appropriate medication (Senna or Miralax are good choices)…
I didn’t have a problem with constipation while taking oipioids and it was not because I wasn’t “compliant.” And I doubt that I’m highly unusual as a pain patient. Forcing unneeded medication on patients is an expense we can’t afford, and alleging that we aren’t compliant because we don’t want to take Miralax is just plain wrong.
-Oxycodone is highly desirable on the street and there are many other opioid alternatives;
oxycodone products should be considered the last line opioid.
-It is becoming increasingly popular to treat patients with very high doses of immediate release
opioid without the use of an extended release opioid. There is absolutely no physiological/ pharmacological reason that immediate release products work fine but extended release products “don’t work for me.” Generally, this is because the immediate release opioids are much easier to abuse and divert than the extended release opioids, not because the extended release opioids “don’t work.”
Immediate release opioids worked better for me than extended release, but that must be because all I wanted to do is abuse and divert them. I mean, why would I want to treat my pain when I can become a millionaire by selling the drugs that help me survive?
See, when you add the potential for addiction to any treatment, then doctors will have to read your mind to figure out what your true intentions are. I’m telling you, the next step will be polygraphs for all pain patients.
-Once a patient reaches an opioid dose of 50 mg MDE, then the patient should be placed on an
extended release opioid product…
Because there are many other chemical systems that participate in maintaining pain, it is perfectly reasonable to start other adjunctive medications (tricyclics, SSRI’s, gabapentin, tizanidine, other anticonvulsants, duloxetine, etc.) to help with chronic pain management at any point in the patient’s treatment. Such adjunct medications should be used in conjunction with taking advantage of side effects they may have that are beneficial (sleep induction for tricyclics and trazadone, for example).
And if those medications don’t help, or if we don’t want to take them because of their side effects, then we must not be in too much pain, right? In other words, if you don’t take these pills, you can’t have these other pills that actually work.
-Daily dosing of “muscle relaxers” is not indicated for the treatment of chronic pain but may be
helpful in treating their disordered sleep. Carisoprodol specifically is NOT recommended for this purpose (oxycodone + diazepam + carisoprodol = “the holy trinity” on the street).
Because what’s happening on the “street” is more important than what works for the patient.
-If benzodiazepines have been prescribed specifically as part of the patient’s pain reduction
treatment, then consideration should be given to discontinuing via a taper. There is no
evidence that this class of medication helps with pain reduction and adverse medication effects are many times more likely when patients are on benzodiazepines and opioids together. If benzodiazepines and opioids are necessary, then consultation with psychiatry is recommended to assist with whatever condition for which the benzodiazepines are needed since they are not indicated for management of chronic pain.
Who wrote these “guidelines”? It doesn’t say, but PFROP is mentioned in the references. I don’t see why anyone needs to see a doctor anymore, as the DEA has already decided how to treat patients.