Chronic non-cancer pain is a significant problem in Canada and it’s growing as our population ages. It’s estimated that 25% of Canadians suffer from chronic pain and the prevalence of chronic pain increases with age. Arthritic conditions are the number one cause (31%) of chronic non-cancer pain with low back pain being the second most common (21%) source. Despite the large number of patients suffering from chronic pain visiting their doctors, more than 60% of physicians and patients feel that moderate to severe chronic pain is not well treated in Canada. (Canadian Chronic Pain Study II, CCPS II).

While pain clinics exist throughout the country, they tend to congregate in or near urban centres in either hospital outpatient settings or in community-based pain clinics. The vast majority of patients are being managed in the community by their family doctors and community-based pain clinics. There’s a significant shortage of pain-focused practitioners nationally and waiting lists in hospital and community-based pain programs can stretch into years.

Chronic pain patients are often complex and require the creativity and patience of a caring physician who is willing to explore numerous therapeutic modalities. Some of these modalities are covered by provincial healthcare plans while others unfortunately are not. These include physical therapies (physiotherapy, chiropractic treatment, TENS, massage therapy, acupuncture, etc.), pharmacological management, interventional treatments (epidurals, anesthetic nerve blocks, Botox, nerve stimulators, surgical intervention), and psychological care including cognitive behavioural therapy. No single therapeutic modality is a panacea and an interdisciplinary approach is often the key to success.

Addiction risk overstated

I often hear colleagues say that “I don’t treat these patients because I don’t want to get them addicted to opioids.” Many studies have clearly demonstrated that in fact a very small percentage of chronic pain patients are actually addicted to opioids. Often, escalating doses are perceived as a sign of addiction when in fact this is “pseudoaddiction,” where patients are being under-treated for their pain and legitimately require a higher dose of medication. Once adequately managed, these behaviours disappear.

There are tremendous similarities in the chronic non-cancer pain management guidelines from Colleges across the country. With respect to pharmacological management, there’s consensus that chronic non-cancer pain patients should be treated with non-opioid adjunct treatments prior to considering opioids. Tricyclic antidepressants, anticonvulsants such as gabapentin (Neurontin) and pregabalin (Lyrica), SNRI’s such as venlafaxine (Effexor), and most recently added duloxetine (Cymbalta) are just a few examples of the commonly used adjuncts for managing chronic pain. In a recent study from Queen’s University, a significant percentage of patients described improved pain and functionality on nortriptyline and gabapentin alone.

If adjuncts and other non-pharmacological modalities have been tried and a patient still requires greater pain control, opioids can be introduced and titrated up to effect balancing of benefits against adverse effects, starting with short-acting opioids and then switching to a sustained-release opioid for optimal continuous pain control. This strategy not only helps ensure continuous pain management as evenly as possible over a 24-hour period, it helps patients avoid the ups and downs of pain, or anticipatory anxiety of the return of pain, and may help poor sleep, one of the most common complaints of chronic pain patients.

Opioid phobia

While there appears to be great fear amongst physicians of investigation and reprimand by regulatory bodies, a review of cases before the Ontario College of Physicians & Surgeons, to give one example, showed only 21 reprimands for improperly prescribing narcotics between 1991 and 2005. This represents only 0.1% of Ontario physicians.

A College official recently told me that not only do complaints about opioid prescribing represent a very small fraction of the complaints that the College receives, there were actually more complaints for refusing to prescribe opioids than for over-prescribing them. Yet there continues to be tremendous opioid phobia and anxiety by physicians, patients, and patients’ families.

Stopping pain is only part of managing it

Regardless of the diagnosis or treatment, the mainstay of patient management should be a focus on functionality and not just absolute reduction in pain score. We need a toolbox for evaluating pain patients, and a small arsenal of tools for maximally managing patients suffering from chronic pain while optimally “bullet-proofing” our practices against possible deceitful patients.

The “6 A’s” assist physicians with a structured SOAP-like note to document progress on a patient in an efficient and organized manner.

Warn patients taking pain medications about sedation early on, and not to drive or use machinery until they’re comfortable that they’re alert. Offer prophylactic education and less sedating medication for itching (e.g. loratadine), anti-emetics for nausea (e.g. prochlorperazine, metochlopramide), anti-constipation strategies (fibre, stool softeners, laxatives) so that they don’t quit taking their medications for minor intolerances that often settle within a few weeks.

Get it in writing

Deciding to whom to prescribe opioids should be a function of diagnosis, individual need, risk profile, balancing possible benefits against potential adverse effects, comorbidities, and your patient agreeing to sign a narcotic agreement with the treating physician.

Assuming that your clinical judgement dictates that a patient may benefit from opioids, you should use a standardized independently validated tool to stratify pain patients into groups at low, medium, or high risk for drug abuse, misuse, or diversion. The Opioid Risk Tool (ORT) is one such tool that can be completed in a very short period of time, especially if the patient is known to your practice. Most patients will be at low risk of drug abuse. Since patients at medium or high risk of abuse can also have a legitimate pain condition, their risk score shouldn’t necessarily preclude them from being treated with an opioid if necessary and appropriate. But your prescribing of opioids for medium and high-risk patients should be more cautious (less quantities dispensed at a time, consulting with a pain or addiction specialist, if one is available in your community, etc.).

Colleges across Canada strongly recommend that, prior to receiving a first opioid prescription, all patients sign an opioid agreement. In it they agree to receive their opioids from only one prescriber and one pharmacy, and to abide by strict rules with respect to medication loss, early refills, possible abuse or diversion. I always write the patient’s and pharmacy’s name on prescriptions, and the quantity of pills dispensed (written in letters and not numbers alone). A duplicate or triplicate prescription pad can help verify the authenticity of opioid prescriptions.

Pitfalls of urine testing

Urine drug screening is an emerging tool being used when prescribing opioids to chronic pain patients. If you’re using urine drug testing, it’s paramount that you are comfortable with its uses and limitations. While a positive drug screen may yield a wealth of information, I alert all physicians that a “negative” urine drug screen in a patient to whom you’ve prescribed opioids to does not necessarily mean that your patient is not taking your medication or diverting your prescription. This often comes as a shock to physicians. Over-reliance on urine test results can lead to a catastrophic error: accusing a bona fide chronic pain patient of diverting your prescription when they may be amongst a significant percentage of the population that are poor metabolizers or rapid metabolizers of commonly prescribed opioids such as codeine and oxycodone.

A negative drug screen provides limited information about your patients’ use or lack of use of your prescribed medications. What it does tell you is that this person hasn’t recently abused illicit drugs such as cocaine, barbiturates, amphetamines, or alcohol (you must specify that you want ETOH screened for on urine drug tests). But many immunoassays won’t detect synthetics or semi-synthetics. Various series have shown that 10% or more of Caucasians are poor metabolizers of codeine, plus 3% of Blacks, 2% of Arabs, and 1% of Asians. Others are rapid metabolizers. The most common opioid prescribed in Canada is codeine, usually with acetaminophen. Codeine requires conversion to the active metabolites via the CYP450 2D6 enzyme. If a patient lacks this enzyme or is taking another medication that may inhibit it (e.g. quinidine, SSRIs), he or she will get little or no benefit from the medication and the drug screen can be negative.

In a recent survey, only 12% of primary care physicians knew that oxycodone was a semi-synthetic and that a specific request must be made to the lab to identify oxycodone in urine drug testing. I regularly see patients wearing fentanyl patches whose urine drug screening results are negative for fentanyl. I was recently consulted by one of the Colleges regarding a patient complaint against a physician for accusing him of diverting his medications based on a negative drug screen. The patient scored “low risk” on numerous screening tools, he had no history of alcohol or drug abuse, he worked full time, and he had never asked for an early refill or lost his medications. He was shocked and dismayed when his physician kicked him out of his practice for having a negative urine drug screen.

Most chronic pain patients are legitimate, decent people cut off in the prime of their lives by an accident, injury, or illness. Many become severely depressed and even suicidal. While complex and multifaceted, pain is a disease and not just a symptom, and these patients need and deserve all our skill,
patience and creativity to help improve their quality of life. While opioids are certainly not the only tool that should be employed in their management, physicians should feel empowered to use a range of non-pharmacological and pharmacological tools — including opioids — to best manage their pain patients, and the various College Guidelines support the safe and careful use of all these modalities.

Using four simple tools (the 6 A’s progress note, a risk assessment tool such as the Opioid Risk Tool, a narcotic agreement, and carefully-interpreted urine drug screening) can empower doctors to confront chronic pain with confidence. There’s tremendous satisfaction to be had in improving the quality of life of chronic pain sufferers, some of the most complex patients in every physician’s practice.