Episode 125: Non-opioid Chronic Pain Management 

Dr. Axelsson and Jesse explain how to treat chronic pain without opioids. 

Written by Anika Soleyn, MS4, Ross University School of Medicine. Edited by Jesse Lamb, MS3, American University of the Caribbean; Hector Arreaza, MD; and Fiona Axelsson, MD.

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Axelsson:Welcome to the first episode of 2023, Happy new year! Today is January 10, 2023.

What is chronic pain?

According to the International Association for the Study of Pain, chronic pain is nonstop or reoccurring pain that lasts more than 3 months or beyond the expected clinical course of illness. Chronic pain can adversely affect well-being and quality of life. We used to think of pain as a response to tissue damage, and as the tissue heals, the pain dissipates, but chronic pain is much more complex than that because there may be no evidence of tissue damage, yet the nociceptors keep sending signals to the brain that there is damage.

There are 3 options for the management of chronic pain: non-pharmacologic, nonopioid pharmacological and opioid management. 

CDC recommends a combination of nonpharmacological and non-opioid management for chronic pain. The 7 most common chronic pain conditions are neuropathic pain, fibromyalgia or chronic pain syndrome, osteoarthritis, inflammatory arthritis, low back pain, chronic headache, and sickle cell anemia.

Opioids in long-term care facilities.

The use of opioids for the treatment of pain is common in the post-acute and long-term care setting. From the AFP Journal, the Choosing Wisely Recommendation states: “Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.” 

The Society for Post-Acute and Long-Term Care Medicine published a statement in 2018 about the use of opioids. It states that the prescription of opioids should be based on an interprofessional assessment specifying why opioids are needed. When long-term opioids are not being used for cancer, palliative care, or end-of-life care in a long-term facility, a tapering plan must be “individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with non-pharmacologic therapies and non-opioid medications”. 

Long-term opioid prescriptions should be reviewed regularly and take into consideration the potential harms of opioids. Clinicians are encouraged to offer alternatives such as behavioral therapy, non-opioid analgesics, and other non-pharmacologic treatments whenever available and appropriate.

Initial assessment: Identify biopsychosocial factors and identify if the source is neuropathic, nociceptive, or central sensitization. This can be a challenging process and it may require several visits to determine the origin of pain. Neuropathic pain is due to nerve damage or irritation while nociceptive pain is due to tissue damage. Central sensitization is an abnormal response of the nociceptive system. There are changes in the nervous system that alter how it responds to sensory input that causes widespread pain with no apparent cause or in response to mild sensory input. Some examples include fibromyalgia, migraines in response to brushing hair, surgical scar pain, etc.

Set goals and expectations: It is crucial to set up patient expectations if they have chronic pain. They should understand that pain can be improved to a manageable