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PATIENT CARE PROCESS

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Patient Care Process for the Management of Pain

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Collect

  • Patient-specific characteristics

  • Pain and symptom-specific history (e.g., onset, location, duration, characteristics, aggravating factors, alleviating factors, timing, and severity).

  • Patient history including current and past medications, allergies or medication intolerance, and pertinent social history (e.g., tobacco, alcohol, or recreational drug use)

  • Family history of illness, focusing on symptoms and social behavior (e.g., alcoholism, recreational drug use)

  • Objective data including vital signs, pertinent labs, targeted physical exam, and drug screen results

Assess

  • Presence of co-occurring mental health conditions (i.e., depression, anxiety, or bipolar) which may confound treatment decisions

  • Aberrant drug taking behaviors as evidenced by prescription drug monitoring programs (PDMP), urine drug screen results, and validated risk screening tools

  • Relative or absolute contraindications to the use of opioids, acetaminophen, antidepressants, anticonvulsants, nonsteroidal anti-inflammatory drugs, or skeletal muscle relaxants

  • Potential drug interactions with any additions or deletions to drug therapy

  • Chronicity of pain symptom (e.g., acute or chronic), likely etiology (e.g., neuropathic, musculoskeletal, or visceral), and severity (Figure 60-2)

  • Determine patient's insurance coverage/ability to pay before making modifications to therapy.

Plan

  • Patient and symptom-specific lifestyle modification (e.g., weight loss, smoking cessation, self-pacing, and pain-trigger avoidance)

  • Nonpharmacologic treatment modalities

  • Drug therapy regimen including dose, route, frequency, and duration (Figure 60-3)

  • Monitoring drug therapy regimen including efficacy, toxicity, misuse, and ongoing necessity using tools such as urine drug screening, PDMP, and risk assessment tools

  • Patient education on safe use, storage, disposal, and risk mitigation following formal risk evaluation and mitigation strategies when available

Implement

  • Educate patient and/or caregiver regarding all elements of disease process and treatment plan, ensuring patient and/or caregiver understanding

  • Informed consent, including pain or treatment agreements when necessary

  • Schedule follow-up

Follow-up: Monitor and Evaluate

  • Assess attainment of treatment goals (e.g., improved activity, improved sleep, improved work attendance)

  • Presence of adverse effects or aberrant drug taking behaviors

  • Completion of validated risk assessment tools

  • Frequent review of PDMP

  • Patient adherence to all facets of treatment plan, including nonpharmacologic modalities

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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

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For the chapter in the Wells Handbook, please go to Chapter 55. Pain Management.

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CONTENT UPDATE

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Content Update

March 13, 2017

New Guidelines for Management of Low Back Pain: In 2017, the American College of Physicians revised the previous 2007 guidelines for non-invasive management of low back pain. Acute, subacute, and chronic low back pain should all be treated initially with nonpharmacologic therapy. Pharmacotherapy should be limited to patients experiencing inadequate response to nondrug treatments, especially those with chronic low back pain. NSAIDs and skeletal muscle relaxants are recommended for acute low back pain. For chronic low back pain, NSAIDs are first-line therapy, and duloxetine and tramadol are second-line agents. Opioids should be limited to patients failing the other agents and in whom the benefits clearly outweigh the risks. There is a lack of studies with long-term follow-up in patients ...

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