Managing Chronic Pain

---
name: managing-chronic-pain
description: Guides multimodal chronic pain management with opioid risk assessment and functional goals. Use when managing chronic pain, assessing opioid risk, or creating pain management plans.
tags:
  - management
  - primary-care
  - risk
metadata:
  author: casemark
  practice_areas:
    - Family Medicine
    - Internal Medicine
    - Primary Care
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Chronic Pain

Guides multimodal chronic pain management with opioid risk assessment and functional goals.

## Why This Skill Exists

Chronic pain affects approximately 50 million U.S. adults, with 19.6 million experiencing high-impact chronic pain that limits daily activities. The CDC Clinical Practice Guideline for Prescribing Opioids (2022 revision) replaced the 2016 guideline with nuanced, patient-centered recommendations that move away from rigid dose ceilings while maintaining emphasis on multimodal therapy and risk mitigation. Simultaneously, state Prescription Drug Monitoring Programs (PDMPs), DEA enforcement, and payer prior authorizations create a complex regulatory environment.

Primary care clinicians prescribe approximately 50% of all opioid prescriptions and must balance compassionate pain management against addiction risk, overdose prevention, and functional outcomes. This skill enforces a structured approach to chronic pain that prioritizes non-pharmacologic and non-opioid therapies, implements standardized risk assessment, and documents functional goals to support both patient outcomes and medicolegal defensibility.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the pain diagnosis (ICD-10) and duration (>3 months = chronic)? **Default: [REQUIRED]**
2. What is the current pain severity (0-10 NRS) and functional impact (PEG scale)? **Default: [REQUIRED]**
3. Has the patient trialed non-pharmacologic therapies (PT, CBT, acupuncture)? **Default: unknown**
4. What non-opioid medications have been tried with results? **Default: unknown**
5. Is the patient currently taking opioids? If so, what agent, dose, and duration? **Default: none**
6. What is the patient's Opioid Risk Tool (ORT) score or DIRE score? **Default: not yet assessed**
7. Has the PDMP been checked within the past 90 days? **Default: no**
8. Does the patient have a history of substance use disorder, mental health diagnosis, or prior overdose? **Default: per history**

### Documents to Request

- Pain diagram (body map) with onset, quality, radiation, and aggravating/relieving factors
- Functional assessment: PEG scale (Pain, Enjoyment, General Activity) or Brief Pain Inventory
- Prior imaging and diagnostic workup relevant to pain diagnosis
- Physical therapy notes and treatment response
- Behavioral health records (CBT for pain, psychology notes)
- PDMP report (most recent 12 months)
- Urine drug screen results (immunoassay + confirmation)
- Opioid Risk Tool (ORT) or Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
- Current pain agreement/treatment contract if established
- Emergency department visit records related to pain

---

## Step 1: Comprehensive Pain Assessment

Document the pain phenotype using the biopsychosocial model:

**Biological:**
- Pain location, onset, duration, quality (nociceptive vs. neuropathic vs. nociplastic)
- Nociceptive: aching, throbbing, localized (e.g., osteoarthritis, mechanical back pain)
- Neuropathic: burning, shooting, tingling (e.g., diabetic neuropathy, radiculopathy)
- Nociplastic: diffuse, widespread, amplified (e.g., fibromyalgia, central sensitization)
- Physical exam findings: ROM, tenderness, neurologic deficits, provocative tests
- Relevant imaging and diagnostics

**Psychological:**
- PHQ-9 for depression (comorbid in 30-50% of chronic pain patients)
- GAD-7 for anxiety
- Pain catastrophizing scale (PCS) if available
- Sleep quality (Insomnia Severity Index)
- History of adverse childhood experiences (ACEs)

**Social:**
- Functional status: work, ADLs, relationships, recreation
- Workers' compensation or disability status
- Social support system
- Substance use history including alcohol, cannabis, illicit drugs

---

## Step 2: Non-Pharmacologic Therapies (First-Line)

CDC 2022 Recommendation 2: Non-pharmacologic therapy is preferred as first-line for chronic pain.

| Therapy | Evidence Base | Conditions | Access |
|---|---|---|---|
| Physical therapy / exercise | Strong (Grade A) | MSK pain, back pain, OA, fibromyalgia | Refer; typically 6-12 sessions |
| Cognitive behavioral therapy (CBT) | Strong (Grade A) | All chronic pain; especially with catastrophizing | Refer pain psychologist |
| Yoga / tai chi | Moderate (Grade B) | Low back pain, fibromyalgia, OA | Community-based; covered by some plans |
| Acupuncture | Moderate (Grade B) | Low back pain, knee OA, headache | Licensed acupuncturist |
| Massage therapy | Low-moderate | MSK pain, myofascial pain | Licensed therapist |
| Spinal manipulation | Moderate for acute/subacute LBP | Low back pain | Chiropractic or osteopathic |
| Mindfulness-based stress reduction (MBSR) | Moderate | Fibromyalgia, chronic LBP | 8-week structured program |
| Interdisciplinary pain rehab | Strong for complex chronic pain | Refractory pain with functional limitation | Tertiary center referral |

Document all non-pharmacologic modalities tried, response, and barriers to access.

---

## Step 3: Non-Opioid Pharmacotherapy (Second-Line)

| Medication Class | Agents | Best For | Key Considerations |
|---|---|---|---|
| NSAIDs | Ibuprofen 400-800mg TID, naproxen 250-500mg BID, meloxicam 7.5-15mg daily | OA, inflammatory pain, MSK | GI risk (add PPI if age >65 or H/O ulcer); renal/CV risk with chronic use |
| Topical NSAIDs | Diclofenac gel 1% QID | Localized OA (knee, hand) | Preferred in elderly; minimal systemic absorption |
| Acetaminophen | 500-1000mg Q6H (max 3g/day; 2g/day if liver disease) | Mild MSK pain, adjunct | Limited efficacy alone for chronic pain |
| SNRIs | Duloxetine 30-60mg daily, venlafaxine 75-225mg daily | Neuropathic pain, fibromyalgia, comorbid depression | Avoid abrupt discontinuation |
| TCAs | Amitriptyline 10-75mg QHS, nortriptyline 10-75mg QHS | Neuropathic pain, headache prophylaxis | Anticholinergic effects; avoid in elderly (Beers criteria) |
| Gabapentinoids | Gabapentin 300-3600mg/day divided TID; pregabalin 75-300mg BID | Neuropathic pain, fibromyalgia | Sedation, abuse potential (pregabalin Schedule V); renal dosing required |
| Muscle relaxants | Cyclobenzaprine 5-10mg QHS, tizanidine 2-8mg TID | Acute MSK spasm (short-term) | Not for chronic use; sedation |
| Topical lidocaine | Lidocaine 5% patch, up to 3 patches for 12 hours on/12 off | Localized neuropathic pain | Minimal systemic effects |
| Capsaicin | 0.075% cream QID or 8% patch (clinic-applied) | PHN, neuropathic pain | Burning initially; 8% patch requires supervised application |

---

## Step 4: Opioid Therapy (When Indicated)

Apply only when non-opioid and non-pharmacologic therapies are insufficient and benefits outweigh risks:

**Pre-initiation requirements:**
1. Complete Opioid Risk Tool (ORT): Low (0-3), Moderate (4-7), High (≥8)
2. Check PDMP (mandatory in most states before initial prescription and every 90 days)
3. Obtain baseline urine drug screen (UDS)
4. Establish treatment agreement documenting: goals, risks, monitoring expectations, taper criteria
5. Set functional goals (not just pain score targets)

**Initiation:**
- Start lowest effective dose of immediate-release opioid
- Typical start: oxycodone 5mg Q6H PRN or morphine IR 15mg Q6H PRN
- Reassess at 1-4 weeks before continuing
- Calculate morphine milligram equivalents (MME): caution at ≥50 MME/day; avoid ≥90 MME/day without pain specialist involvement

**Ongoing monitoring:**
| Monitoring Element | Frequency | Tool |
|---|---|---|
| Functional assessment (PEG) | Every visit | PEG scale |
| PDMP check | Every 1-3 months (per state law) | State PDMP database |
| UDS | Random, ≥1-2x/year; more if high-risk | Immunoassay + confirmation |
| Pill counts | Random or every visit for high-risk | In-office count |
| Naloxone co-prescribing | At initiation; update as needed | Naloxone nasal spray 4mg |

---

## Step 5: Opioid Taper and Discontinuation

Indications for taper: lack of functional improvement, adverse effects, aberrant behaviors, patient request, dose ≥90 MME without specialist co-management.

- Taper rate: reduce 5-10% of total daily dose every 2-4 weeks
- Slower taper (5% per month) for patients on long-term therapy (>1 year)
- Never abruptly discontinue in physically dependent patients (risk of withdrawal, uncontrolled pain, suicidality)
- Manage withdrawal: clonidine 0.1mg BID-TID, loperamide for GI symptoms, hydroxyzine for anxiety
- If substance use disorder identified: transition to buprenorphine/naloxone (Suboxone) with appropriate X-waiver (eliminated as of Jan 2023 per MAT Act)
- Warm handoff to addiction medicine or behavioral health

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the pain diagnosis specific (not just "chronic pain") with ICD-10 code?
2. Are non-pharmacologic and non-opioid therapies documented as tried or planned before opioid initiation?
3. Has opioid risk assessment been completed with documented score?
4. Are functional goals (not pain score targets) defined and measurable?
5. Is the monitoring plan (PDMP, UDS, follow-up intervals) documented?

---

## Quality Audit

- [ ] Pain diagnosis documented with specific ICD-10 code and duration
- [ ] Biopsychosocial assessment completed (biological, psychological, social domains)
- [ ] Functional assessment performed with validated tool (PEG, BPI, or Oswestry)
- [ ] Non-pharmacologic therapies documented as tried, in progress, or referred
- [ ] Non-opioid medications trialed before opioid initiation
- [ ] ORT or SOAPP-R completed and scored before opioid prescribing
- [ ] PDMP checked and documented before initial opioid prescription
- [ ] Treatment agreement signed and filed if opioids prescribed
- [ ] UDS obtained at baseline and per monitoring schedule
- [ ] MME calculated and documented; rationale for doses ≥50 MME/day
- [ ] Naloxone co-prescribed for patients on opioids (especially ≥50 MME/day)
- [ ] Functional goals defined with measurable outcomes
- [ ] Co-occurring depression/anxiety screened and addressed
- [ ] Taper plan documented if opioids are being reduced or discontinued
- [ ] Specialist referral (pain management, behavioral health) considered for refractory cases

---

## Guidelines

- Never prescribe opioids as monotherapy for chronic pain; always combine with non-pharmacologic and non-opioid therapies
- The CDC 2022 guideline explicitly recommends against rigid application of dose thresholds (e.g., 90 MME ceiling) as hard limits; individualize based on risk-benefit
- Benzodiazepine + opioid co-prescribing dramatically increases overdose death risk (FDA black box warning); avoid combination or document compelling rationale
- Urine drug screens require confirmation testing (GC-MS or LC-MS/MS) before acting on unexpected results—immunoassays have significant false positive/negative rates
- Methadone requires QTc monitoring (ECG at baseline, 30 days, annually) due to arrhythmia risk and has nonlinear pharmacokinetics—refer to pain specialist for initiation
- Never abruptly discontinue opioids in a physically dependent patient; forced tapers have been associated with overdose, suicidal ideation, and transition to illicit opioid use
- Document every PDMP check with date, findings, and clinical interpretation in the medical record
- Workers' compensation and disability cases require separate documentation standards; consult jurisdiction-specific requirements