CDC Recommendations

Patients with co-existing psychiatric disorders should receive ongoing mental health support and treatment while being treated for chronic pain. Unless the prescriber treating the patient is qualified to provide the appropriate care and evaluation of the coexisting psychiatric disorder, consultation should be obtained to assist in formulating the treatment plan and establishing a plan for coordinated care of both the chronic pain and psychiatric conditions.

Because psychological distress frequently interferes with improvement of pain and function in patients with chronic pain, use validated instruments such as the Generalized Anxiety Disorder (GAD)-7 and the Patient Health Questionnaire PHQ-9 or the PHQ-4 to assess for anxiety, post-traumatic stress disorder, and/or depression (205).

Opioid therapy should not be initiated during acute psychiatric instability or uncontrolled suicide risk. Prescribers should consult a behavioral health specialist for any patient with a history of suicide attempt or psychiatric disorder. In addition, patients with anxiety disorders and other mental health conditions are more likely to receive benzodiazepines, which can exacerbate opioid-induced respiratory depression and increase the risk for overdose. For treatment of chronic pain in patients with depression, prescribers should strongly consider using tricyclic or SNRI antidepressants for analgesic as well as antidepressant effects.

Opioid treatment should be discontinued when pain problems have been resolved, treatment goals are not being met, adverse effects outweigh benefits, or dangerous or illegal behaviors are demonstrated.

Dangerous or illegal behaviors may include:

- Frequent requests for refills prior to the expected use date.
- Positive urine drug screens for non-prescribed medications.
- Negative urine drug screens for opiates that have been prescribed that patient states they are taking.
- Suspicion of diverting medications to others.

The decision to discontinue opioid treatment should ideally be made jointly with the patient and the family/caregivers when appropriate (Federation of State Medical Boards, (2004). This decision requires careful consideration of the treatment outcomes and the need to provide ongoing monitoring.

When the patient is discharged, the prescriber is obliged to offer continued monitoring for 30 days post-discharge. Once a provider-patient relationship is established, the prescriber owes a continuing duty to provide care until that relationship is appropriately terminated. Prescribers should adhere to the standard of care for their specific discipline when dismissing a patient. The failure to do so may constitute neglect or abandonment.

Prescribers should obtain a consultation for a patient with complex pain conditions or serious comorbidities.

Reasons to refer patients include:

The prescriber has reached a limit of what he or she feels comfortable prescribing.
- The treatment needs a multi-disciplinary approach.
- The pain has progressed to a complex level.
- Significant risk factors for substance use disorder are identified.
- There is a need to re-evaluate the patient’s diagnosis or confirm the continued diagnosis.

A multidisciplinary approach for chronic pain may result in a better outcome compared to medical management alone. The results generally indicate a reduction in pain, better functional restoration, reduced healthcare costs, higher return-to-work rates, and reduced disability costs.

Patients with serious comorbidities may benefit from a palliative care consultation if the goal is to improve a person’s quality of life while living with chronic or serious illness. These patients usually have exhausted other traditional therapies for their illnesses (congestive heart failure, COPD, advanced cancer) or live with a high symptom burden during treatment of their illness. They are not hospice eligible, because they live longer than a traditional hospice patient or may have aggressive medical goals. Patients that receive palliative care may have less frequent hospitalizations, improved quality of life, and improved physical function.