A chronic pain patient should be evaluated periodically once started on a treatment plan.
Frequency of follow-up visits:
(1) after initiation: 1-2 weeks
(2) then: every month until stable
(3) stable: at least every 2-3 months
Assessments:
(1) Perform a history and physical exam.
(2) Current pain status and recent pain history.
(3) Document functional status and progress towards functional goals.
(4) Review interim reports (radiology, laboratory tests, consultant, etc).
(5) Identify barriers and resources.
(6) Evaluate status of medical and psychiatric comorbidities.
(7) Update changes in psychological and social determinants.
(8) Consider referral to specialist for drug addiction, psychiatric disorder or pain.
General therapy:
(1) Determine the level of adherence to medications and treatment plan.
(2) With each new prescription review benefits vs risk of therapy.
(3) Consider new treatment modalities and non-pharmacologic interventions.
(4) Evaluate for adverse drug effects.
(5) Document pain response to treatment plan. Identify any pain generators. Adjust plan as needed.
Opioid Therapy:
(1) Calculate and monitor MMED. Avoid MMED > 50 unless clear benefit. Do not exceed MMED 90.
(2) Titrate effective medications. Taper down the opioid dose if there is no improvement in function or if there is risk of misuse or if there are adverse effects.
(4) Discontinue ineffective treatments. Consider opioid discontinuation.
(5) Prescribe naloxone if the MMED is > 50, if there is a history/risk of overdose, or if the patient is on a benzodiazepine.
(6) If a stable patient requests an increase in dose, then consider tolerance or opioid failure or misuse or condition progression.
(7) Consider buprenorphine therapy if not currently receiving.
Substance use:
(1) Update changes in substance use (alcohol, tobacco, recreational).
(2) Assess for red flag behaviors that may indicate addiction or diversion. Screen for opioid use disorder.
(3) Review pain agreement with patient.
(4) Perform a pill count if high risk for misuse.
(5) Check the prescription drug monitoring program (PDMP) with each prescription. Look for multiple prescribers, use of multiple pharmacies, unreported controlled substances.
(6) Order a urine drug screening test at least once a year, more often if high risk for misuse.
