Review Article

Management of Chronic Noncancer Pain in the Primary Care Setting

Authors: Bruce Nicholson, MD, Steven D. Passik, PhD

Abstract

While opioids are regarded as the mainstay of chronic pain management, their use is controversial in the minds of many primary care physicians due to clinical concerns about dependence, abuse, and addiction and medicolegal concerns regarding state and federal regulatory authorities. For patients with moderate to moderately severe pain, the treatment of choice is a long-acting opioid or opioid combination drug product to provide sustained analgesia along with improvements in sleep quality, compliance, and possibly quality of life. Careful screening of patients being considered for long-term opioid therapy with validated questionnaires can identify patients who may have difficulties in managing opioids. These patients should not be denied access to opioid therapy, but they do require focused monitoring and case management. Ongoing monitoring should focus on the 4 A’s (ie, analgesia, activities of daily living, adverse effects, and aberrant drug-related behaviors), and all aspects of patient care must be thoroughly documented.


Key Points


* Despite clinical and medicolegal concerns about issues of dependence, abuse, and addiction, in clinical use, opioids are efficacious and safe in selected patients.


* The treatment of choice for patients with chronic, moderate to moderately severe pain is a controlled-release formulation of an opioid or opioid combination drug designed to provide sustained analgesia, improved sleep quality, compliance, and quality of life.


* The role of immediate-release opioid formulations in the treatment of chronic, moderate to moderately severe pain is to provide analgesia when breakthrough pain occurs.


* Careful screening of patients being considered for long-term opioid therapy can identify patients who may have difficulties in managing opioids.


* Opioid therapy should not be denied to these patients, but they require focused monitoring and case management.


* Ongoing monitoring should focus on the 4 A’s: analgesia, activities of daily living, adverse effects, and aberrant drug-related behaviors.

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