Pain Management

Pain is a complex physiologic response that is complicated by biological, psychological and social factors and can be categorized as acute, subacute or chronic depending on the duration. Chronic pain is defined as lasting longer than 3 months. The approach to chronic pain management, particularly opiate prescribing, has evolved over the last several decades from pain being the fifth vital sign and hence requiring aggressive suppression, to a more measured patient focused strategy.

The Oregon Medical Board (OMB) recognizes that the assessment, prevention and treatment of chronic pain is complex and must be tailored for individual patients and situations. Importantly, clinical judgement combined with shared decision making focused on function and quality of life for each individual person should inform treatment plans as it relates both to non-pharmacological and pharmacological therapies.

On November 3, 2022, the Centers for Disease Control and Prevention (CDC) revised its guidelines for pain management to provide a more flexible approach to treating pain and to provide broader evidence-based recommendations. See: CDC Clinical Practice Guideline for Prescribing Opioids for Pain and Factsheet: CDC Guideline for Prescribing Opioids for Chronic Pain.

OMB licensees are advised to read the guidelines and familiarize themselves with the standards of care in pain management and opiate prescribing, including Medication-Assisted Therapy (buprenorphine, methadone, suboxone).

While the OMB guidance has historically focused mainly on opiate prescribing, condition specific, non-pharmacological modalities are discussed throughout the current CDC guidelines. These recommendations include but are not limited to RICE, acupuncture, acupressure, exercise, heat, massage, non-cervical spine manipulation, TENS, and remote electrical neuromodulation. Also discussed in these guidelines are non-opiate medications such as NSAIDs, selective antidepressants, and anticonvulsants among others.

As it relates to opiates, prescribers should conduct a patient-centered evaluation when determining an approach to opiate use and appropriate Morphine Equivalent Dose (MED) for each unique patient. Prescription Drug Monitoring Program (PDMP) checks and detailed counseling conversations with patients – and documentation of these – remain critically important. The risks versus benefits of opioid treatment for chronic pain and frequency of drug screens are to be considered on a case-specific basis. The new guidance makes clear the ongoing assessment and documentation of the benefits of opiates and all controlled substances versus the risks and side effects is still of paramount importance in maintaining health and wellbeing for patients.

Finally, the OMB's prescribing webpage has additional resources available for licensees. References include several specialty guidelines and toolkits along with Oregon CME requirements and Oregon specific guidelines. See: omb.oregon.gov/pain.