Assuming care of a chronic pain patient already on opioids can pose a number of challenges.
(1) perform a complete history and physical
(2) take a full medication history, including pain medicines that worked or did not work
(3) obtain and review the patient's past medical records
(4) determine the total MME per day of most recent prescription
(1) the diagnosis
(2) the most likely pain mechanisms
(3) the continued need for opioid therapy
Contraindications/cautions to continued opioid therapy:
(1) concurrent benzodiazepine or other sedatives
(2) red flags for possible misuse
(3) central pain mechanism
(4) significant adverse effects including opioid-induced hyperalgesia
(5) comorbid conditions associated with respiratory depression
Indications for opioids:
(1) improved function while on opioids, with benefits outweighing adverse effects
(2) adheres to recommended standards
(3) no alternative therapy that is equivalent or superior
If opioids are appropriate, then manage as a chronic pain patient on opioids.
(1) Identify the patient's goals.
(2) Check the prescription drug monitoring program (PDMP) database
(3) Perform a urine drug screen.
(4) Provide the required patient education.
(5) Have the patient sign the patient-physician drug agreement.
(6) Have the patient provide informed consent.
If opioids are no longer appropriate:
(1) identify a more appropriate therapeutic plan
(2) taper and discontinue the opioid therapy
If the practice cares for chronic pain patients, then there should be standard protocols for management that can be used by on-call providers.
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