La. Admin. Code tit. 40 § I-2104

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-2104 - Overview of Chronic Pain Management

A. It is estimated by the Institute of Medicine that approximately 100 million adults suffer from chronic pain in the United States. The World Health Organizations survey found that 37 percent of adults in 10 developed countries have chronic pain conditions. This overview covers the biopsychosocial nature of chronic pain and a comprehensive plan of care including: functional assessment and goal setting, psychological assessment, medication management, sleep considerations, and active therapy assisted by international pain management procedures with continued therapy afterwards as well as indicated surgery.

B. Chronic pain may develop from persistent acute pain due to neuroplastic changes occurring in the central nervous system. All chronic pain appears to involve a central sensitization which changes the perception of pain. Thus, treatment patterns are aimed at a number of mechanisms contributing to chronic pain.

C. Chronic pain is recognized as a biopsychosocial disease process. Each treatment plan should be individualized with a patient-centered approach addressing the many available treatment combinations. Therefore, all areas of the chronic pain guideline should be considered when developing a treatment plan. This includes: the mandatory psychological evaluation; an active therapy plan; medications specific to the pain process for that patient; continuing functional assessment; complementary medication alternatives, when appropriate; and continued return to work/regular daily activity.

D. Once a patient has been identified as a chronic pain patient, usually three months after an injury when pain persists or when pain persists beyond a reasonable postoperative period, the physician should perform a complete re-evaluation or may refer the patient to a pain specialist or surgeon for consultation. This will assist both the patient and the provider in developing an appropriate treatment plan. Although it is unusual to identify an unknown pathology at this point in the treatment, it is recommended that the provider acknowledge the full complement of patient symptoms and concerns. Repeating or ordering new imaging may be necessary.

E. It is essential that the patient and provider understand the type of pain the patient is experiencing and how the pain affects day-to-day activities. Identifying the presence of neuropathic pain, as well as any sources of nociceptive pain, will assist the patient and provider when choosing medication and other forms of treatment recommended in the guideline.

F. During the chronic pain assessment, it is suggested that all physicians review with the patient their usual activities over several different typical 24-hour periods. This will assist both parties in understanding what functions are not able to be performed by the patient, how significantly sleep is impacted, and whether pain is affecting social and family relationships. This information is also essential for establishing agreed upon functional goals.

G. All chronic pain patients should have psychological evaluations. Patients may merely need assistance with coping mechanisms, and/or anxiety or depression may be caused or exacerbated by chronic pain. Treatment in this area is essential for the chronic pain patient. Cognitive behavioral sessions are frequently effective for these conditions.

H. Review of the current prescribed and over-the-counter medications is an important part of this initial chronic pain evaluation. If the patient has been chronically on opioids, a pain specialist referral should be considered to identify the necessity of the opioids and the proper dose. It is also reasonable to taper opioids in order to determine the patients baseline and how other medications are actually affecting the pain.

1. The following is a general summary of the required elements. A number of other guidelines, including the Centers for Disease Control and Prevention (CDC) for Primary Care Practitioners and Board of Medical Examiners, have confirmed these steps.

a. An opioid trial shall be performed before chronic opioids are determined to be useful for patients. About 50 percent of patients will not be able to tolerate the side effects and/or not show a sufficient increase in function with opioid use. Patients should be aware that this is a trial and like any other medication trial, it will not be continued unless there is sufficient benefit. The average benefit is about a 30 percent decrease in pain. Thus, all other required treatment must be continued during the time period of the chronic opioid trial.

b. Long acting opioids should never be used for acute pain, post-operative pain, or before an opioid trial has been completed. There is no evidence they are more beneficial than short acting opioids, and the trial should begin with short acting opioids.

c. A risk assessment tool, such as the Opioid Risk Tool (ORT) or Screener and Opioid Assessment for Patients with Pain (SOAPP) should be completed to assure the provider that there are no prior elements suggesting substance abuse or, when such elements are present, the physician may choose to refer to a provider with more expertise in substance abuse.

d. Urine drug testing should be done prior to initiating controlled substance.

e. Check the Prescription Monitoring Program (PMP). Follow Louisiana Revised Statutes 40:973, 40:978 and 40:978.3.

f. The psychological evaluation should have been completed and hopefully treatment as appropriate is being continued.

g. A functional history should be taken and functional goals should be set. This needs to be followed throughout all chronic pain treatment to determine if the patient is increasing or decreasing in function.

h. A provider physician agreement must be completed. This is extremely helpful as it reviews for the patient the expectations regarding his/her behavior as well as the expectations regarding when a physician would choose to taper or remove the patient from opioids and what other treatment is expected to continue during an opioid trial.

2. If the opioid trial is successful, the physician should continue to monitor with random drug testing and PMP checks. "Random drug testing" should be four times a year or possibly more with documented suspicion of abuse or diversion. Quantitative testing is appropriate in cases of inconsistent findings, suspicions, or for particular medications that patient is utilizing that is not in the qualitative testing. In addition, the Current Opioid Misuse Measure (COMM) is an example of a tool that can be used for patients on opioids to screen for possible abuse. It should be noted that current estimates suggest approximately 14 to 19 percent of chronic opioid users may become addicted to opioids.

I. The patient will need to be monitored for side effects. Constipation is anticipated. There may also be problems with sexual dysfunction. Opioids may increase or cause sleep apnea problems, and this should be monitored. At all visits, the functional status of the patient should be recorded.

This can be accomplished with reliable, patient-reported functional status tools. Function is preferably validated by physical exam or by other objective measures from the provider.

J. Lack of sleep is a significant problem for patients with uncontrolled chronic pain. Taking a good history in this area and promoting an appropriate sleep regime is essential for patients, if they are to establish a productive life-style.

K. Active therapy is one of the most important components. Regular exercise is shown to decrease depression as well as decrease chronic pain. Helping the patient choose appropriate physical activities and cognitive activities will be important for recovery. Physician directed exercise, home stretching exercise, does not have to be formal course of physical therapy (as long as the patient has previously undergone a formal course of physical therapy).

L. Although treating chronic pain patients is challenging due to the many disciplines and treatment patterns available, the rewards are great when a patient with chronic pain is able to resume work and engage in satisfying life activities.

La. Admin. Code tit. 40, § I-2104

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 46196 (2/1/2020).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.