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Management of Non-Malignant Chronic Pain in Primary Care – Adult – Ambulatory

Management of Non-Malignant Chronic Pain in Primary Care – Adult – Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Pain and Sedation


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Management of Non-Malignant Chronic
Pain in Primary Care – Adult –
Ambulatory Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 4
METHODOLOGY .................................................................................................................... 4
DEFINITIONS.......................................................................................................................... 5
INTRODUCTION ..................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................ 6
Assessment and Treatment Plan ................................................................................................. 6
Non-Pharmacologic Interventions .............................................................................................. 8
Pharmacologic Interventions (Excluding Opioids) .................................................................... 11
Prescribing Opioids .................................................................................................................... 12
Transitions of Care (When to Consider A Consult Or Referral) ................................................. 18
UW HEALTH IMPLEMENTATION ........................................................................................... 23
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 25
CONSIDERATIONS FOR SHARED DECISION MAKING CONVERSATIONS WITH PATIENTS WITH
CHRONIC PAIN1,3 ................................................................................................................. 26
REFERENCES ........................................................................................................................ 27
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Contact for Content:
Name: Alaa Abd-Elsayed, MD- Anesthesiology
Email Address: abdelsayed@wisc.edu
Name: Matthew Anderson, MD- Medicine- Internal Medicine/General
Email Address: mcanders@medicine.wisc.edu
Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Coordinating Team Members:
Nathan Rudin, MD- Ortho/Rehab- Rehab General
Bruce Baranski, MD- Medicine- Internal Medicine/General
William Seiden, MD- Medicine- Internal Medicine/General
Jason Dambach, MD- Medicine- Internal Medicine/General
Katherine Porter, DO- Family Medicine
Dave Ringdahl, MD- Family Medicine
Aleksandra Zgierska, MD, PhD- Family Medicine, Addiction Medicine
Alex Young, MD- Family Medicine
John Myers, MD- Director of Medical Affairs (SwedishAmerican Health System)
Chantal Girod, MD- Family Medicine (SwedishAmerican Health System)
Matthew Thomas, MD- Addiction Medicine Fellow
Philip Trapskin, PharmD, BCPS- Drug Policy Program
Cheryl DeVault, BSN, RN, OCN- Family Medicine Clinic Operations Manager
Linda Kiefer, RN- Family Medicine
Laura LaCoursiere, RN- Medicine- Internal Medicine/General
Joan Bradley- General Internal Medicine Clinic Coordinator
Julie Christofferson, RN, MSN- Clinical Staff Education Manager
Tracy Crowley- Clinical Staff Educator
Ellen Runkel- Health Link Ambulatory Operations Manager
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Katherine Le, PharmD- Center for Clinical Knowledge Management (CCKM)
Kevin Straka- Center for Clinical Knowledge Management (CCKM)
Jennifer Kuroda- Quality Improvement Manager (SwedishAmerican Health System)
Review Individuals/Bodies:
Randall Brown, MD, PhD, FASAM- Family Medicine, Director of Center for Addictive Disorders
Donald Wiebe, PhD- Clinical Laboratories
Heidi Rechter- General Internal Medicine RN Clinic Manager
Adam Rindfleisch, MD- Family Medicine, Medical Director of Integrative Health
Cheryle Sickels RN, BSN- Integrative Health Clinic Manager
Kristen Traino, MS, PT- Outpatient Rehabilitation Manager
Tiffany Houdek, PT, MPT- Physical Therapist- Advanced Clinician
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 04/27/2017)
Release Date: April 2017 | Next Review Date: April 2019
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Executive Summary
Guideline Overview
This guideline contains a compilation of recommendations derived from the Wisconsin Medical
Examining Board Opioid Prescribing Guideline, 2016 CDC Guideline for Prescribing Opioids for
Chronic Pain, and local expert consensus and individual review of the published literature.1-3
These recommendations are meant to assist clinicians in treating and managing chronic pain in
patients seem within the primary care setting, including the unique needs of patients on chronic
opioid therapy.
Key Practice Recommendations
1. Patients who presents for chronic pain treatment in primary care should have a thorough
evaluation/assessment completed upon initial presentation and during periodic follow-up.2
(UW Health Low quality evidence, strong recommendation)
2. It is strongly recommended that exercise is included as a component of the treatment plan,
regardless of pain source or type.4 (UW Health Moderate quality evidence, strong
recommendation)
3. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic
pain.1 Clinicians should consider opioid therapy only if expected benefits for both pain and
function are anticipated to outweigh risks to the patient. If opioids are used, they should be
combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as
appropriate.1,3 (CDC recommendation category: A; evidence type: 3)
4. When considering increasing the opioid dosage to 50 morphine milligram equivalents (MME)
or more per day, clinicians should develop a plan for ongoing risk assessment and
mitigation that includes components in the additional considerations for patients on opioid
therapy section. Pill counts can also be completed at least annually (or more frequently if
concerns for misuse or abuse and violations of the controlled substances medication
agreement).2 (UW Health Very low quality evidence, strong recommendation)
5. Clinicians should avoid increasing opioid dosage to 90 MME or more per day or carefully
justify and appropriately document in the patient’s medical record a decision to titrate
dosage to 90MME or more per day.2 (UW Health Very low quality evidence, strong
recommendation).Concurrent use of opioids and benzodiazepines might put patients at
greater risk of overdose. Clinicians should avoid prescribing opioid pain medication and
benzodiazepines concurrently whenever possible.1,3 (CDC recommendation category: A;
evidence type: 3)
6. It is strongly recommended that a primary care clinician consider consulting a pain specialist
earlier in the course of chronic pain treatment, when non-pharmacologic and non-opioid
therapies have been unsuccessful, as opposed to much later when the chronic pain has
become intractable, especially for comprehensive assessment.5 (UW Health Low quality
evidence, strong recommendation)
Companion Documents
1. Pain Management Profile Quick Reference & Interpretation Guide (Urine Drug Screening)
2. Prescription Drug Monitoring Program (PDMP)
3. CDC Resources for Calculation of Morphine Milligram Equivalent Conversions
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Scope
Disease/Condition(s): Chronic Pain, excluding cancer-related pain, terminally ill patients with a
life expectancy of less than 6 months, and patients enrolled in a hospice/palliative care program
Clinical Specialty: Primary Care
Intended Users: Physicians, Advanced Practice Providers, Nursing, Pharmacists
Objective(s):
ξ To outline evidence-based recommendations for the non-pharmacologic and
pharmacologic management of chronic pain in the primary care setting.
ξ To outline recommended conditions for when to refer to Specialty Care (i.e., Pain Clinic,
Addiction Medicine).
Target Population: Adult patients age 18 years or older diagnosed with chronic pain.
Interventions and Practices Considered:
ξ Non-pharmacological methods of pain management
ξ Pharmacologic methods, including the use of controlled substances
ξ Initiation and further management and monitoring of opioid therapy
Major Outcomes Considered:
ξ Pain reduction or control
ξ Improved function
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1).
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Figure 1.

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: For all guidelines, review the literature
and/or describe published or suspected health care disparities (e.g., racial, ethnic,
socioeconomic, etc.). Include a brief literature review or recommendations for addressing these
issues in the care provided when appropriate.
Definitions
Chronic pain: pain or discomfort that persisted continuously or intermittently for longer than 3
months.6

Addiction: Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial,
and environmental factors influencing its development and manifestations characterized by one
or more of the behaviors: compulsive use/impaired control over use, continue use despite harm
due to use and/or preoccupation with use/craving.7
Introduction
Since 1999, the number of prescription painkillers prescribed has quadrupled with no
corresponding drop in pain reported by Americans. As a result, the United States is in the midst
of an opioid epidemic where the number of deaths from opioids has also quadrupled since 1999
and it is estimated that 1.9 million Americans aged 12 years or older have an opioid use
disorder.8 Complicating this matter is that prescription opioids continue to be a mainstay for pain
treatment, especially for patients suffering from various chronic pain disorders.

Given accessibility issues to pain specialists and poor insurance reimbursement for
interdisciplinary team care to treat pain, patients are relying on primary care services to manage
their chronic pain.9,10 This guideline is meant to assist clinicians in treating and managing
chronic pain patients in the primary care setting especially patients who are on chronic opioid
therapy.
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Recommendations
ASSESSMENT AND TREATMENT PLAN
1. Patients who present for chronic pain treatment in primary care should have a thorough
evaluation/assessment completed upon initial presentation and during periodic follow-up.2
(UW Health Low quality evidence, strong recommendation)
2. Consistent evaluation can improve monitoring and identification of changes in conditions
(e.g. medication use, functional activities being performed). It is recommended that the
following components are considered in each evaluation/assessment where chronic pain is
addressed (UW Health Low quality evidence, strong recommendation)2:
a. Physical examination and diagnostic testing targeted to the pain condition which
seek to determine signs of inflammation, abnormal sensory findings, and/or loss of
function.
b. Review of the Problem List to identify any underlying or co-existing diseases or
conditions, including those which could complicate treatment (e.g., renal disease,
sleep apnea, Chronic Obstructive Pulmonary Disease, etc.).
c. Review of medical history, including any history of substance abuse or psychiatric
disorders associated with substance abuse or opiate abuse (i.e. depression, post-
traumatic stress disorder, borderline disorder, or other dissociative disorders).11-15
d. Review of social history to identify employment status, social support systems, etc.
e. Review of family history, including history of substance abuse.
f. A comprehensive pain interview that includes a detailed pain history (i.e., current and
past treatments and response to each treatment) and evaluation of the nature and
intensity of pain. Either the Brief Pain Inventory or the PEG-3 can be completed
during the initial evaluation and follow-up assessments.16-18 (UW Health Low quality
evidence, weak/conditional recommendation) The PEG-3 was derived from the BPI,
validated in primary care patients, and exhibits the advantage of only being
composed of 3 questions (i.e., shorter administration time).16
g. Assessment of functional status to identify the impact of pain on quality of life and
activities of daily living. The impact of pain on functional status may be assessed
using the validated questions within the Brief Pain Inventory, questions within the
PEG-3, or the Physical Functional Ability Questionnaire (FAQ5). (UW Health Low
quality evidence, weak/conditional recommendation) Despite its lack of validation,
consensus recommendations from health systems across the United States use the
FAQ5 to evaluate functional ability based on its ease of use and the clinical
relevance of the questions.
h. Assessment of the impact of pain on emotional function, including identification of
how pain affects patient mood and whether the patient has any coping strategies for
managing the pain. Patients should be screened for depression using the Patient
Health Questionnaire-2 (PHQ-2) and Patient Health Questionnaire-9 (PHQ-9).14,19-21
(UW Health Low quality evidence, strong recommendation) Anxiety can be assessed
using the Generalized Anxiety Disorder (GAD-7).22 (UW Health Very low quality
evidence, weak/conditional recommendation)
i. If psychosocial or behavioral health conditions are identified, clinicians should
conduct further evaluation and manage appropriately. For patients with
depression, consider referencing the recommendations within the UW Health
Depression – Adult/Pediatric – Ambulatory Clinical Practice Guideline.
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3. Patients who engage in collaborative care, shared decision-making and chronic disease
self-management have improved health outcomes.23 Good communication between health
care providers and patients can promote adherence to pain treatments and improve
outcomes.24 It is recommended that the patient and primary care provider develop a
treatment plan together, which is reviewed regularly and revised as necessary based on
response to interventions or changes in health status.24-26 (UW Health Low quality evidence,
strong recommendation) The treatment plan should include the following components:
a. Clear, individualized pain management goals (e.g., physical and psychosocial
function, pain level goal target)
b. Non-pharmacologic pain management strategies
c. Pharmacologic interventions (if any)
d. Procedural interventions performed by primary and/or specialty care (if any)
e. Self-care strategies for managing chronic pain such as managing weight, smoking
cessation, and improving sleep hygiene.

Additional Considerations for Patients on Opioid Therapy
Clinicians should follow applicable state statutes and local organizational policy (i.e., UW Health
Policy 1.2.3- Opiate Management).The following recommendations outline best practice
supported by the evidence and local expert opinion. Mandatory minimum standards of care are
outlined within the UW Health Policy 1.2.3- Opiate Management.
1. Before starting and periodically during opioid therapy, clinicians should discuss known risks
and realistic benefits of opioid therapy with patients as well as patient and clinician
responsibilities for managing therapy (see Appendix for Shared Decision-Making Talking
Points).1,3 (CDC recommendation category: A; evidence type: 3)
a. Informed consent should be obtained from all patients who are prescribed chronic
opioid therapy. (UW Health Low quality evidence, strong recommendation)
b. A written Controlled Substances Medication Agreement should be completed as part
of an ongoing treatment plan for all patients receiving chronic opioid therapy. (UW
Health Low quality evidence, strong recommendation) The medication agreement
establishes clear expectations and avoids reliance on physician judgement,
suspicion, or bias. The required frequency for completion of the Controlled
Substance Medication Agreement is outlined in UW Health Policy 1.2.3- Opiate
Management.
2. Clinicians should evaluate opioid risk abuse potential using the D.I.R.E Score: Diagnosis,
Intractability, Risk and Efficacy prior to prescribing opioids.27 (UW Health Moderate quality
evidence, strong recommendation)
3. Before starting (or continuing) opioid therapy, clinicians should establish opioid-specific
treatment goals and consider how opioid therapy will be discontinued if benefits do not
outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful
improvement in pain and function that outweighs risks to patient safety.1,3 (CDC
recommendation category: A; evidence type: 4)
4. Clinicians should review the state prescription drug monitoring program (PDMP) data when
starting opioid therapy for chronic pain and periodically during opioid therapy for chronic
pain, ranging from every prescription to every 3 months.1,3 (CDC recommendation category: A,
evidence type: 4) The required frequency for review of the PDMP is outlined in UW Health
Policy 1.2.3- Opiate Management. Review of the patient’s history of controlled substance
prescriptions can be used to determine whether the patient is receiving opioid dosages or
dangerous combinations that put them at high risk for overdose.1,3
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5. When prescribing opioids for chronic pain, clinicians should use urine drug screening
(Patient Management Profile) before starting opioid therapy and should consider urine drug
screening, at least annually.1,3 (CDC recommendation category: B, evidence type: 4)
a. In patients on opioid therapy, clinicians should assess for the presence of prescribed
medications as well as other controlled prescription drugs and illicit drugs.1,3 (CDC
recommendation category: B, evidence type: 4)
b. Detailed information to support accurate ordering and interpretation of urine drug
screening results (including metabolites, detection time, etc.) can be found on
uConnect (https://uconnect.wisc.edu/clinical/references/opiate/providers/drug-
testing/resources/name-83298-en.file).
6. Consensus guidelines recommend routine reassessment/follow-up every 3-6 months.1,2 (UW
Health Low quality evidence, weak/conditional recommendation) Several low quality studies have
demonstrated that the likelihood of long-term therapy increases after continuous opioid use
for greater than 90 days.28,29
a. Follow-up may be completed during a clinic office visit, telephone encounter,
MyChart contact, or RN patient outreach.
b. Per UW Health Policy 1.2.3- Opiate Management, follow-up is required at least twice
a year to discuss chronic pain management (where one visit must be with the
patient’s primary care provider).
c. During follow-up assessments, use of the same assessment tools (e.g., Brief Pain
Inventory, FAQ5, PHQ-2/PHQ-9) completed during the initial evaluation should be
considered to improve consistent monitoring of longitudinal progress of pain
management and patient goals or outcomes.
NON-PHARMACOLOGIC INTERVENTIONS
1. An overwhelming number of guidelines on chronic pain conditions recommend patients
utilize non-pharmacologic strategies in treating their chronic pain. The Centers for Disease
Control (CDC) Guideline for Prescribing Opioids states that nonpharmacologic therapy and
nonopioid pharmacologic therapy is preferred for chronic pain.1 However, while these
guidelines encourage non-pharmacologic interventions, very few cite specific modalities that
patients should use given the lack of strong data. It cannot be overemphasized how
important it is to incorporate non-pharmacologic interventions into a patient’s chronic pain
treatment plan.
2. It is strongly recommended that exercise is included as a component of the treatment plan,
regardless of pain source or type.4 Exercise can improve chronic pain symptoms and
functional status, bolsters overall health, and encourages the patient to be an active
participant in his or her treatment program. (UW Health Moderate quality evidence, strong
recommendation)
a. Patient education should be provided to help patients distinguish new symptoms that
may signify problems from the “good” discomfort typically resulting from exercise.4
(UW Health Low quality evidence, strong recommendation) Patients typically experience a
flare-up of pain with exercise which is exacerbated by poor body mechanics,
guarded or stiff movement, high levels of demand on an injured site, or
compensatory movements.
b. As many chronic pain patients are physically deconditioned from inactivity, a graded
or progressive physical therapy approach may be considered to minimize risk of
exercise-related injury, improve tolerance, and maximize patient participation and
compliance.4,30 (UW Health Low quality evidence, weak/conditional recommendation)
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3. Besides exercise, patients may benefit from other non-pharmacologic interventions as they
engage the patient and promote physical and social activity, which may help address
psychosocial and emotional distress related to pain. Moreover, whether or not a non-
pharmacologic intervention has been studied in treating a patient’s type of pain should not
preclude it from an individual’s treatment plan. Incorporation of any non-pharmacologic
intervention should be made with consideration of the appropriateness of the intervention
relative to a patient’s physical capability, engagement, and sustainability of the intervention.
(UW Health Low quality evidence, strong recommendation)
a. Figure 2 outlines non-pharmacologic interventions which have been studied in
certain types of pain.31-38
b. Tables 1-2 summarize the potential impact, safety concerns, describe which specific
patient populations may benefit most from an intervention, and outline local
community resources.33
4. Consults or referrals to services provide by specialists (e.g., Physical Therapy, Occupational
Therapy, Integrative Health) may be needed to maximize patient engagement and education
on the variety of non-pharmacologic approaches (see When to Consider Consult or Referral
section). (UW Health Low quality evidence, weak/conditional recommendation)


Figure 2. Suggested Non-Pharmacologic Interventions by Pain Type31-38


Note: Patients with osteoarthritis pain should be managed using the recommendations within the UW
Health Osteoarthritis of the Knee and Hip – Adult – Ambulatory Clinical Practice Guideline.


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Table 1. Non-pharmacologic Interventions for Chronic Non-Malignant Pain4,31-39
Treatment Efficacy/Impact Safety Considerations Evidence Grade
Exercise
Reduces pain relative to usual
care or attention control,
improves physical functioning
and self-efficacy.
No reported safety issues Strongly consider in chronic low back pain, fibromyalgia and older adults with persistent
pain
UW Health Moderate quality
evidence, strong recommendation
Aquatic therapy May improve physical function
and pain
No reported safety issues May be beneficial for individuals with comorbidities that cannot tolerate weight-bearing
exercise (e.g. low back pain); beneficial for fibromyalgia patients with depression or anxiety
UW Health Low quality evidence,
weak/conditional recommendation
Tai chi
Studies suggest effective
treatment in improving physical
functioning
No serious adverse
events, minor adverse
events include muscle
soreness and increased
joint pain
Low-impact exercise that may help individuals with joint problems, arthritis, low back pain
and fibromyalgia

Consider in older patients with persistent pain, if delivered appropriately
UW Health Low quality evidence,
weak/conditional recommendation
Qi-gong May improve sleep and physical
function
No reported safety issues May help fibromyalgia patients UW Health Low quality evidence, weak/conditional recommendation
Yoga
May help improve sleep, reduce
stress and anxiety and improve
strength and flexibility
No serious adverse events
May help fibromyalgia patients
May improve pain and function in low back pain patients compared to usual care however
mixed results when compared to exercise/stretching

Consider in older patients with persistent pain
UW Health Low quality evidence,
weak/conditional recommendation
Cognitive- behavioral
Therapy (CBT)
May help reduce pain and
disability /improve how patients
think and cope with pain
No serious adverse events
May help fibromyalgia patients in reducing pain and disability with sustained long term
results
May help older patients if delivered by professional
UW Health Moderate quality
evidence, weak/conditional
recommendation
Biofeedback Can include relaxation training No serious adverse events
Limited to no evidence can improve sleep or fatigue in fibromyalgia patients

May be used in multi-disciplinary pain management program
UW Health Low quality evidence,
weak/conditional recommendation
Acupuncture
Can reduce pain and functional
disability relative to sham
controls
No serious adverse
events; minor events
include bruising, bleeding
at needle insertion sites
May consider as adjunctive therapy in older patients
May improve pain and function in low back pain patients compared to usual care

May not be effective for fibromyalgia symptoms treatment
UW Health Low quality evidence,
weak/conditional recommendation
Mindfulness meditation Can be used to supplement CBT No serious adverse events
May help improve pain in fibromyalgia patients versus usual care ; limited to evidence may
help older patients with persistent pain
UW Health Low quality evidence,
weak/conditional recommendation
Massage May reduce pain and improve
functioning
No serious adverse events May consider as adjunct therapy in an older adult; modest pain improvement demonstrated
for low back pain patients at 10 weeks but not sustained at 52 weeks
UW Health Low quality evidence,
weak/conditional recommendation
Self-management
education
program/support group
May reduce pain and improve
functioning
No serious adverse events May enhance benefits from exercise in fibromyalgia patients; consider in older patients with
persistent pain
UW Health Low quality evidence,
weak/conditional recommendation
Transcutaneous
electric nerve
stimulation
(TENS)

Percutaneous
electrical nerve
stimulation (PENS)
May improve pain quality and
functioning
May be a complex
intervention due to
complex pattern of usage
and multiple direct/indirect
outcomes
May reduce in chronic pain patients when used as complementary treatment to other
treatments (e.g. medications)
PENS may reduce pain and improve sleep for painful diabetic neuropathy
UW Health Low quality evidence,
weak/conditional recommendation
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PHARMACOLOGIC INTERVENTIONS (EXCLUDING OPIOIDS)
The Centers for Disease Control (CDC) Guideline for Prescribing Opioids states that
nonpharmacologic therapy and nonopioid pharmacologic therapy is preferred for chronic pain.1,3
The following table (Table 2) outlines the first and second line agents primary care providers
should prescribe based on the pain physiology (e.g., nociceptive, neuropathic, or inflammatory).
Condition specific recommendations can also be found in the following resources:
ξ UW Health Osteoarthritis of the Knee and Hip – Adult – Ambulatory Clinical Practice
Guideline.
ξ UW Health Assessment and Treatment of Migraine – Adult – Ambulatory/Emergency
Department Guideline
ξ UW Health Assessment and Treatment of Migraine– Pediatric – Ambulatory/Emergency
Department Clinical Practice Guideline

Table 2. Non-Opioid Medications for the Management of Chronic Pain
Pain
Physiology40
Class
Medication Usual Dose Ranges for Adults
Para-aminophenol derivatives
Nociceptive*
1st line
Acetaminophen41 500-1000mg every 4-6 hours (not to exceed 4000mg/24hours)
Nonsteroidal Antiinflammatory Drugs (NSAIDs)
Nociceptive*
1st line

Inflammatory
1st line

Propionic acid derivatives
Ibuprofen42 200-800mg PO every 4-6hours ( not to exceed 3200mg/24hours)
Naproxen43,44 220-500mg PO 2 times daily
Oxaprozin45 1200mg PO once daily
Acetic acid derivatives
Diclofenac46-49
(IR) 50mg PO 2-3 times daily or (XR) 100mg PO once daily
Topical gel: 2-4 grams to area of pain up to 4 times (maximum of 32
grams/24 hours)
Patch: One patch to most painful area up to twice daily
Nabumetone50 1000-2000mg PO once daily
Salicylates
Aspirin51 325-1000mg PO every 4-6hours (not to exceed 4000mg/24hours)
Enolic acid derivatives
Piroxicam52 20mg PO once daily
Meloxicam53 7.5-15mg once daily
Selective COX-2 Inhibitors
Celecoxib54 200-400mg in 1-2 divided doses once daily (not to exceed 400mg/24hours)
Anticonvulsants
Neuropathic
1st line
Gabapentin40,55,56
(IR) Initiation: 300mg once day 1, 300mg 2 times daily on day 2, 300 mg 3
times daily on day 3, titrated as needed to a maximum dose of 400-600mg
PO 3 times daily
(ER) Initiation: see package insert to titrate to daily dose of 1800mg PO
daily
Pregabalin57 Initiation: start at 150 mg PO per day in 2-3 divided doses, with target dose
of 150-300mg twice daily.
Tricyclic antidepressants40
Neuropathic
1st line
Amitriptyline
Nortriptyline
Desipramine
Initiation: 10-25mg PO at bedtime
May titrate every 2 weeks to 75-100mg PO every night at bedtime
Serotonin and Norepinephrine Reuptake Inhibitors
Neuropathic
1st line
Duloxetine58 Initiation: 20-30mg PO daily, titrate weekly to target dose of 60mg PO daily
Venlafaxine XR40
(long-acting)
Initiation: 37.5mg PO daily, titrate weekly to target dose of 150-225mg PO
daily
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Pain
Physiology40
Class
Medication Usual Dose Ranges for Adults
Spasmolytics
Nociceptive*
2nd line

Baclofen59
Initiation: 5mg PO 3-4 times daily, may increase by 5mg per dose as often
as every 3 days until optimal response is reached. Usual dose is 40-80mg
in divided doses daily.
Tizanidine60
Initiation: 2mg PO up to 3 times daily (at 6- to 8-hour intervals); may titrate
to optimal effect in 2-4 mg increments per dose (with a minimum of 1-4
days between dose increases);maximum: 36 mg/24hours
Miscellaneous
Nociceptive*
2nd line

Neuropathic
2nd line
Lidocaine61,62
Patch 4%OTC, 5%Rx: 1-3 patches daily to region of pain for up to 12 hours
each day
Cream 5% or Ointment 5%: Apply up to 5grams (roughly six inch strip) up
to 4 times daily.

Nociceptive*
2nd line

Neuropathic
3nd line
Capsaicin topical
cream63 Up to 4 times daily to region of pain
*Nociceptive pain represents the normal response to a noxious insult or injury of tissues such as skin, muscles,
visceral organs, tendons, joints, or bones.64
PRESCRIBING OPIOIDS
The CDC found no evidence for outcomes of long-term (>1 year) opioid therapy for chronic pain
outside of cancer and end-of-life care. However evidence suggests risk for serious harms with
opioid use that appears to be dose-dependent.1,3

Determining when to initiate or continue opioids for chronic pain
1. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic
pain.1,3 Clinicians should consider opioid therapy only if expected benefits for both pain and
function are anticipated to outweigh risks to the patient. If opioids are used, they should be
combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as
appropriate.1,3 (CDC recommendation category: A; evidence type: 3)
2. Opioid therapy should NOT be considered for patients with osteoarthritis related pain.65-68
(UW Health Moderate quality evidence, strong recommendation) Refer to the UW Health
Osteoarthritis of the Knee and Hip – Adult – Ambulatory Clinical Practice Guideline for
additional information.
Opioid selection, dosage, and duration
1. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release
opioids instead of extended-release/long-acting (ER/LA) opioids.1,3 (CDC recommendation
category: A; evidence type: 4) The CDC’s clinical evidence review found a fair-quality study
showing a higher risk for overdose among patients initiating treatment with ER/LA opioids
than among those initiating treatment with immediate-release opioids.69 Furthermore, the
CDC guideline group did not find evidence that continuous, time-scheduled use of ER/LA
opioids is more effective or safer than intermittent use of immediate-release opioids or that
time-scheduled use of ER/LA opioids reduces risks for opioid misuse or addiction. In
addition, it was concluded that there was not enough evidence to determine the safety of
using immediate-release opioids for breakthrough pain when ER/LA opioids are used for
chronic pain outside of active cancer pain, palliative care, or end-of-life care, and that this
practice might be associated with dose escalation.
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2. When opioids are started, clinicians should prescribe the lowest effective dosage
(Table 3).1,3 (CDC recommendation category: A; evidence type: 3)
a. Emerging low quality evidence outlines that the psychopharmacological profile of
oxycodone may have a higher risk of abuse, misuse compared to morphine.70 In
addition, the Wisconsin Medical Examining Board has taken a position to discourage
the use of oxycodone as a first line agent.2 However, there is insufficient evidence to
draw strong conclusions if there are differences amongst opioids (morphine or
oxycodone) in terms of effectiveness or harms.71,72
Table 3. Immediate-release (IR) Opioid Dosing
Opioid Starting Dose
Modified
Starting
DoseA
Duration of
action Follow-up Frequency
B

Morphine IR73 15-30 mg Q4h PRN

5-15 mg Q4h
PRN

2-6 hours
Evaluate benefits and harms
with patients within:
ξ 1 to 4 weeks of starting an
opioid or of dose
escalation.C
ξ At a minimum of every 6
months with continued
therapy.
Oxycodone
IR74
5-10 mg PO Q4-
6h PRN

2.5-5 mg PO
Q4-6h PRN

3-6 hours
A
Consider modified opioid starting dose and/or frequency for patients at increased risk of adverse events
or patients for which lower doses may achieve adequate analgesia. Applicable patients may include (but
are not limited to): age ≥65 years, adults weighing fewer than 50 kg, renal or hepatic impairment.74,75
B
Follow-up may include an assessment completed during a clinic office visit, telephone encounter, Health
Link MyChart contact, or RN patient outreach.
C Risk of overdose may be highest in the first 3-7 days after opioid initiation or dose increase.1,3

3. The decision to increase an immediate-release opioid dose or frequency should be based
upon individual patient response. It may be reasonable for patients with inadequate
response within the first 1-2 hours after an oral dose to consider increasing the patient’s
dose; and for patients that inadequately sustain response to consider increasing the dosing
frequency. (UW Health Low quality evidence, weak/conditional recommendation)
4. For patients with a successful trial of an immediate release opioid, it may be reasonable to
convert to an ER/LA opioid formulation to minimize dosing frequency, awakening, and drug
blood concentration fluctuation. (UW Health Very low quality evidence, weak/conditional
recommendation)
5. To convert from immediate release to an ER/LA formulation of the same drug and route, it
is recommended to do the following (UW Health Moderate quality evidence, weak/conditional
recommendation):
a. Morphine
i. Arymo ER®, MS Contin®: Total daily oral morphine dose may be
administered either in 2 divided doses daily (every 12 hours) or in 3 divided
doses (every 8 hours).76,77
ii. Avinza®: Total daily morphine dose administered once daily. The first dose of
may be taken with the last dose of the immediate-release morphine.
Maximum: 1,600 mg daily due to fumaric acid content.78
iii. Kadian®: Total daily oral morphine dose may be either administered once
daily or in 2 divided doses daily (every 12 hours).79

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b. Oxycodone
i. Oxycontin®, Xtampza ER®: When converting from oxycodone, divide the 24-
hour oxycodone dose in half to obtain the twice a day (every 12hours)
dose.80,81
6. When considering increasing the opioid dosage to 50 morphine milligram equivalents (MME)
or more per day, clinicians should develop a plan for ongoing risk assessment and
mitigation that includes components in the additional considerations for patients on opioid
therapy section. Pill counts can also be completed at least annually (or more frequently if
concerns for misuse or abuse and violations of the controlled substances medication
agreement).2 (UW Health Very low quality evidence, strong recommendation)
7. Clinicians should avoid increasing opioid dosage to 90 MME or more per day or carefully
justify and appropriately document in the patient’s medical record a decision to titrate
dosage to 90MME or more per day.2 (UW Health Very low quality evidence, strong
recommendation).
8. Concurrent use of opioids and benzodiazepines might put patients at greater risk of
overdose. Clinicians should avoid prescribing opioid pain medication and benzodiazepines
concurrently whenever possible.1,3 (CDC recommendation category: A; evidence type: 3)
9. It is reasonable to avoid the use of acetaminophen-opioid combination products to decrease
the risks for liver injury. (UW Health Low quality evidence, weak/conditional recommendation) In
2014 the FDA recommended health care professionals discontinue prescribing and
dispensing prescription combination drug products that contain more than 325 milligrams
(mg) of acetaminophen per tablet, capsule or other dosage unit to reduce the risk of severe
liver injury from inadvertent acetaminophen overdose, which can lead to liver failure, liver
transplant, and death.82
10. Methadone should not be the first choice for an ER/LA opioid and should only be initiated or
dose adjusted by clinicians familiar with methadone’s unique risk profile and who are
prepared to educate and closely monitor their patients.1,3 (UW Health Very low quality
evidence, strong recommendation)
11. Transdermal fentanyl should only be initiated or dose adjusted only clinicians who are
familiar with the dosing and absorption properties and are prepared to educate their patients
about its use.1,3 (UW Health Very low quality evidence, strong recommendation)
12. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting
opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and
harms of continued therapy with patients every 3 to 6 months or more frequently. If benefits
do not outweigh harms of continued opioid therapy, clinicians should optimize other
therapies and work with patients to taper opioids to lower dosages or to taper and
discontinue opioids.1,3 (UW Health Low quality evidence, strong recommendation)
Assessing risk and addressing harms of opioid use
Before starting and periodically during continuation of opioid therapy, clinicians should evaluate
risk factors for opioid-related harm. Clinicians should incorporate into the management plan
strategies to mitigate risk, including considering offering naloxone when factors that increase
risk of opioid overdose are present. 1,3(CDC recommendation category: A; evidence type: 4) The
CDC guideline workgroup found insufficient evidence to determine how harms of opioids differ
depending on patient demographics or comorbidities. However, based upon the contextual
evidence review and expert opinion, the following risk factors are likely to increase susceptibility
of opioid related harms: sleep-disordered breathing, pregnancy, renal or hepatic insufficiency,
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patients aged > 65 years, mental health conditions, prior nonfatal overdose, substance use
disorder.

Chronic Opioid Dosage Reduction, Taper or Discontinuation

When to Taper
Clinicians should evaluate individual patient benefits and risks of chronic opioid therapy dosage
reduction, taper, or discontinuation in the following scenarios;):
a. patient request,
b. patient’s risk/adverse effects from continued therapy outweigh benefits,
c. receiving opioids for > 3 months and there is no sustained clinically meaningful
improvement in function as measured by a validated instrument,
d. patient experiences a severe adverse outcome or overdose,
e. nonadherence to a controlled substance agreement,
f. patients exhibits behaviors suggestive for addiction,
g. patient is on dosages > 50 MME/day without benefit or using opioid in combination
with benzodiazepines.83,84 (UW Health Very low quality evidence, strong recommendation)

How to Taper
1. It is reasonable to establish the rate (immediate-months) of the taper/reduction based upon
the precipitating event(s) that led to the decision to taper/reduce (i.e. misuse/abuse vs.
efficacy) and patient specific factors (i.e. duration of opioid use, current dosage, medical and
psychological comorbidities). 83,84 (UW Health Very low quality evidence, weak/conditional
recommendation)
2. Coordination with specialists is recommended for tapering in the setting of pregnancy, opioid
use disorder, parasuicidal acts, and severe impulse control disorders. (UW Health Very low
quality evidence, strong recommendation)
3. There is a paucity of literature examining the pace of opioid tapering in chronic non-cancer
pain, so approaches used in addiction medicine are often used as a surrogate.85 It is
reasonable to start with a reduction of 10-25% of the dose in milligrams every 3-7 days to
minimize adverse effects associated with opioid withdrawal.84,86,87 (UW Health Very low quality
evidence, strong recommendation)
4. For patients on benzodiazepines and opioids, sequential tapering of the opioid first and then
the benzodiazepines is reasonable. 84 (UW Health Very low quality evidence, weak/conditional
recommendation). The rationale being that tapering both at the same time may exacerbate
opioid withdrawal side effects (e.g. anxiety, restlessness).
5. In those individuals with regimens that include immediate-release and ER/LA preparations, it
is reasonable to taper the immediate-release opioids first and then the ER/LA opioids.84 (UW
Health Very low quality evidence, weak/conditional recommendation)
6. It is recommended that tapers for the purposes of opioid discontinuation be unidirectional
and should not be reversed, but the rate may be slowed or paused for management of
withdrawal symptoms.84 (UW Health Very low quality evidence, strong recommendation)
Management of Withdrawal during Taper
1. The primary signs and symptoms of opioid withdrawal are the result of rebound sympathetic
nervous system stimulation (due to lack of antagonism from the opioids) such as: anxiety,
hypertension, tachycardia, restlessness, mydriasis, diaphoresis, tremor, piloerection,
nausea, abdominal cramps, diarrhea, vomiting, anorexia, dizziness, hot flashes, shivering,
myalgias, arthralgias, lacrimation, insomnia, and yawning.88,89
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2. The Clinical Opiate Withdrawal Scale (COWS) and Subjective Opiate Withdrawal Scale
(SOWS) can be used to aid clinicians in identification of the degree of withdrawal.90 (UW
Health Very low quality evidence, weak/conditional recommendation)
3. The use of benzodiazepines for opioid withdrawal signs and symptoms is not
recommended.84 (UW Health Very low quality evidence, strong recommendation)
4. Non-pharmacologic interventions (e.g., meditation, exercise, sleep hygiene, etc.) can be
used to manage symptoms of withdrawal via stress reduction and distraction.91,92 (UW Health
Low quality evidence, weak/conditional recommendation)
5. It is reasonable to consider the use of alpha-adrenergic agonists (e.g. clonidine) to reduce
opioid withdrawal symptoms.83,93 (UW Health Moderate quality evidence, weak/conditional
recommendation) When used to support opioid withdrawal, clonidine may be used orally or
transdermally at doses of 0.1 to 0.3mg every 6-8 hours, with a maximum dose of 1.2 mg
daily.85,94 (UW Health Low quality evidence, weak/conditional recommendation)
6. Patients with severe symptoms refractory to preliminary interventions should be considered
for telephone/electronic consultation or in-person clinic visits with a specialist (see When to
Consider Consult or Referral section). (UW Health Low quality evidence, weak/conditional
recommendation)
Co-prescribing Overdose Rescue Agents
1. It is reasonable to prescribe naloxone rescue therapy to any individual who is at risk of
experiencing opioid-related overdose or any other person who may assist a person at risk
for an opioid related overdose.95 (UW Health Moderate quality evidence, weak/conditional
recommendation)
2. The provider should confirm availability of naloxone rescue therapy at the pharmacy, and
that the patient will have access to appropriate education on the prescribed therapy. (UW
Health Very low quality evidence, strong recommendation). All UW Health pharmacies have
naloxone rescue therapy and pharmacists trained to provide necessary patient education.
3. It is recommended to prescribe naloxone rescue therapy for chronic opioid patients meeting
any of the following criteria(UW Health Low quality evidence, weak/conditional
recommendation):1,3,96
a. Experienced a previous opioid overdose
b. History of any substance abuse disorder
c. Concern for returning to a high dose to which patient is no longer tolerant (e.g. recent
release from prison)
d. Prescribed > 50 MME/day
e. Prescribed benzodiazepines
4. It may be reasonable to prescribe naloxone rescue therapy for chronic opioid patients who
meet any of the following criteria:1,3,96 (UW Health Low quality evidence, weak/conditional
recommendation):
a. Have difficulty accessing timely emergency medical services (i.e. distance,
remoteness)
b. Liver, kidney or pulmonary disease
c. Mental health disorder
d. Sleep-breathing disorder
5. For opioid overdose, there are multiple options for community naloxone distribution.
a. Intranasal (Narcan®) 4mg two-pack: Administer a single spray (4mg) into one
nostril. Administer additional doses, using a new nasal spray with each dose, if
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patient does not respond or responds and then relapses in to respiratory depression.
Additional doses may be given every 2-3 minutes until emergency medical
assistance arrives.97
b. UW Health Intranasal Kit (Naloxone 2mg/2mL (2mL syringe X 2), nasal atomizer X1,
CPR face shield) –Administer one-half of the syringe into each nostril for total dose
of 2mg. Administer additional doses, using a new syringe, if patient does not
respond or responds and then relapses in to respiratory depression. Additional
doses may be given every 2-3 minutes until emergency medical assistance arrives.95
c. Intramuscular/Subcutaneous (Evzio auto injector®): Administer 2mg intramuscularly
or subcutaneously into the outer thigh, through clothing if necessary. Administer
additional doses, using a new auto-injector, if the patient does not respond or
responds and then relapses into respiratory depression. Additional doses of may be
given every 2 to 3 minutes until emergency medical assistance arrives.98
d. UW Health Injectable kit (naloxone 0.4mg/mL (1mL syringe x 2), 3 mL empty syringe
X 2, 23-gauge 1.5 inch needle X2, CPR face shield): Administer 0.4mg
intramuscularly or subcutaneously into the outer thigh. Administer additional doses,
using a new auto-injector, if the patient does not respond or responds and then
relapses into respiratory depression. Additional doses of may be given every 2 to 3
minutes until emergency medical assistance arrives.95
Management of Infractions to the Controlled Substances Medication Agreement
1. If a patient violates the treatment agreement, a frank discussion should occur between the
provider and patient addressing the violation. It is recommended that the infraction
discussion serve as an opportunity to reevaluate, enhance and intensify treatment. (UW
Health Low quality evidence, strong recommendation)
2. If the primary care provider is considering intensifying monitoring/opiate safety precautions,
consideration should be given to the five domains of structure(UW Health Low quality evidence,
weak/conditional recommendation)7:
a. Setting of care (e.g. primary care versus involving specialist such as addiction
medicine)
b. Selection of treatment (e.g. selecting a drug with a lower street value)
c. Supply of medication (e.g. controls on amount of medication dispensed)
d. Supports for recovery (i.e. implementation and documentation of recovery activities)
e. Supervision and monitoring (e.g. more frequent visits, pill counts, increased
frequency of urine drug screening). 99
3. Patients who have violated the medication agreement with displays of aberrant behavior
(e.g. early refill requests) may still be managed by primary care per UW Health Policy 1.2.3-
Opiate Management and UW Health Policy 1.2.6- No Further Service.7
4. For other procedural guidance, refer to UW Health Policy 1.2.3- Opiate Management.

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TRANSITIONS OF CARE (WHEN TO CONSIDER A CONSULT OR REFERRAL)

To Physical Therapy or Occupational Therapy
1. A referral to therapy should not be considered in patients who have successfully completed
a course of appropriate physical exercise for chronic pain management, in patients who
refuse, or when exercise is contraindicated. (UW Health Very low quality evidence,
weak/conditional recommendation)
2. Not all patients require physical therapy to actively engage in physical movement or
exercise; however certain groups of patients are likely to achieve better health outcomes
with formal physical therapy. Physical therapy may be appropriate in cases of acute flare-up
of chronic pain or significant changes in status of a patient’s chronic pain condition. (UW
Health Very low quality evidence, weak/conditional recommendation)
3. It is recommended for a primary care clinician to consider referring a patient to physical
therapy or occupational therapy for any of the following conditions (UW Health Low quality
evidence, weak/conditional recommendation):
a. Assistance in improving or developing home-based treatment interventions, which
take into account an individual patient’s goals and any preexisting conditions.5,33,100
b. Recommendations on new assistive/mobility devices.33
c. Provide manual therapy which has been shown to increase range of motion, improve
the quality of the tissues, and reduce pain.
d. Provide posture awareness and body mechanic instruction.
e. Patients with osteoarthritis pain should be managed using the recommendations
within the UW Health Osteoarthritis of the Knee and Hip – Adult – Ambulatory
Clinical Practice Guideline.

To Integrative Health
It may be especially useful to refer patients for an Integrative Health consult when any of the
following conditions are met (UW Health Very low quality evidence, weak/conditional
recommendation):
a. The patient expresses a desire to use complementary and integrative health (CIH)
approaches to support conventional treatments. This may include utility of mind-body
approaches, herbal anti-inflammatories, acupuncture, manipulative therapies, biofield
therapies, nutrition, movement (including yoga and Tai Chi), and/or self-management
practices.
b. To initiate alternative approaches and assist with design of a treatment plan to
support tapering of opioid therapy by other providers (as relevant).
c. The patient is unwilling or unable to work with conventional methods (particularly
medications or surgery), but expresses a willingness to explore other approaches.
d. The patient is very complex (e.g., multiple chronic physical conditions, psychosocial
challenges, or a combination of both).
e. The patient has a specific issue that is either recalcitrant to conventional biomedical
approaches or for which conventional approaches are not readily available.
f. The patient would benefit from additional time to focus on self-management
planning, particularly with regards to self-care.
g. The patient is already using a number of complementary approaches and an
evaluation of safety would be helpful (e.g., multiple dietary supplements and
medications simultaneously with concern or questions for interactions).
h. For creation of an evidence-informed, self-care focused, personal health plan that
could guide ongoing care by either the primary care team or specialists.

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To a Medical or Surgical Specialist
It is recommended for a primary care clinician to consider referring a patient to a medical or
surgical specialist if any of the following conditions are met (UW Health Low quality evidence,
weak/conditional recommendation):
a. The cause of the pain is unknown and there is a need for help with diagnosis or
verification of a diagnosis.5
b. A procedure or surgery is indicated.5
c. There is no curative treatment readily available and/or current treatment is not
helping.

To a Pain Specialist
1. It is strongly recommended that a primary care clinician consider consulting a pain specialist
earlier in the course of chronic pain treatment, when non-pharmacologic and non-opioid
therapies have been unsuccessful, as opposed to much later when the chronic pain has
become intractable, especially for comprehensive assessment.5 (UW Health Low quality
evidence, strong recommendation)
2. Appropriate referrals from primary care clinicians to a pain specialist may include, but are
not limited to, the following (UW Health Very low quality evidence, weak/conditional
recommendation):
a. To further assist with risk/benefit assessment of chronic opioid therapy (e.g., patient
is on ≥ 50 MMEs per day, the patient has been on opioid medications ≥ 1 year, or
clinician suspects patient has developed significant tolerance to opioids).9
b. If there is no curative treatment readily available and/or current treatment is not
helping (e.g., to solicit other pain treatment recommendations in cases of refractory
pain despite appropriate preliminary interventions).9
c. To assist in tapering a patient off opioids (e.g., developing recommended taper
schedule that the primary care clinician can execute themselves).
d. To aid with a complex pain condition (e.g. trigeminal neuralgia, thoracic outlet
syndrome, etc.). 9,101
e. If patient is candidate for adjunctive treatments, such as epidurals.9
f. Assistance in treatment options for a patient with significant co-morbidities (e.g.
chronic pain patient with psychiatric comorbidities already taking anticonvulsants and
antidepressants).9
g. For multidisciplinary assessment of the pain condition (e.g. complex regional pain
syndrome).

Table 5 is an algorithm that may be helpful to the primary care clinician in determining the most
appropriate setting or specialist for the patient’s pain management (e.g. psychiatry, pain
specialist, addiction specialist).


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Table 5. Determining the Appropriate Setting for Pain Management7
Clinical
Parameter
Primary Care Specialist Care
Pain Etiology Clear, straightforward etiology
of pain
Uncertain etiology, by
some physiological
clues or a suggestive
pattern of pain
Etiology unknown, no physiological
clues, no familiar pattern or complex
treatment needs

Consider consult to the Pain Clinic
Psychiatric
Disorder
No history of psychiatric
disorder
Stable, well-
compensated
psychiatric disorder
Psychiatric instability

Consider consult to Psychiatry or Pain
Psychology
Addiction No history of substance
abuse or addiction
In recovery or history
of major substance
abuse
Active addiction, current illicit use

Consider consult to Addiction Medicine
Social Support Good social support Some social discord or
challenging social net
Isolated, major social distress,
destructive associates

Consider consult to Psychiatry, Pain
Psychology, or Health Psychology
Activity
Engagement Rich work or avocational life
Some engagement
with meaningful
activities
No satisfying work, recreation, or other
activities

Consider consult to Pain Psychology,
Occupational Therapy, Psychiatry or
Health Psychology

Communication between Pain Specialist and Primary Care
1. An in-person evaluation and consultation by a pain specialist may not always be needed for
certain referral reasons. Reasons a primary care clinician may seek a brief consultation
include creating an appropriate and feasible opioid taper schedule for a patient,
recommendation for alternate therapies for chronic pain condition with known etiology,
additional medication dose selection or adjustment questions. (UW Health Very low quality
evidence, weak/conditional recommendation)
2. It is very important that the primary care physician and pain specialist maintain regular and
effective communication where both parties are working collaboratively to develop a
sustainable treatment plan and are informed of any pain-management agreements. (UW
Health Very low quality evidence, strong recommendation)
3. Given the high-abuse potential for narcotic medications, it is also important that providers
alert each other to behaviors that put the patient at risk.100 (UW Health Very low quality
evidence, strong recommendation)
When to Resume Care in Primary Care
1. It is not recommended for a chronic pain patient to have their pain managed long term by a
pain medicine specialist if the pain is stable (e.g. pain not worsening, functional status is not
declining) with no therapeutic changes (e.g. dose escalations, medication changes) for at
least 3 months. (UW Health Very low quality evidence, weak/conditional recommendation)
2. A patient whose pain treatments are within the scope of practice for a primary care provider
to maintain and sustain or the patient has a treatment plan that can be monitored and
maintained mainly by a primary care provider may no longer require specialist care
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management for his or her chronic pain. (UW Health Very low quality evidence, weak/conditional
recommendation)
3. Effective communication helps to ensure a smooth transition of care for a patient back to
primary care for ongoing maintenance and implementation of the pain treatment plan.5 A
formal hand-off is recommended to drive consistent communication and documentation
between providers. (UW Health Very low quality evidence, weak/conditional recommendation) The
hand-off should include the following components:
a. Summary of historical treatments provided and their impact of success in treating the
chronic pain.
b. Explicit recommendations or sign-off of the treatment plan which includes monitoring
requirements, unique dosing or tapering, and/or a description of patient
preferences/goals as applicable.
c. Recommendations for when to consult the specialist again.
d. Review of the care team and make modifications as necessary.

To an Addiction Specialist
1. Patients with chronic pain who display aberrant behavior should be seen by an addition
specialist. (UW Health Low quality evidence, weak/conditional recommendation)
2. If medication misuse (i.e. use for reasons other than for which prescription was intended) or
a substance use disorder are suspected, then steps for referral to Addiction Specialist
services should be initiated. (UW Health Low quality evidence, weak/conditional recommendation)
3. Medication diversion is often difficult to differentiate from misuse or a substance use
disorder. The following tables (Table 6-7) can be used to support providers in evaluating
patient behavior and identifying patients who may have an addition problem. Addiction
specialist services may also be considered to assist in this ascertainment.

Table 6. American Society of Addiction Medicine (ASAM), American Pain Society (APS)
and American Academy of Pain Medicine (APM) Criteria Suggestive of Misuse or
Addiction in Patients with Pain
Components of Addiction7,102
The “3 Cs” Possible Expressions in Patients on Chronic Opioid Therapy
Loss of Control
1. Reports lost/stolen medications
2. Uses medication supply in short periods of time and calls for early
refills
3. Seeks opioids from other sources
4. Exhibits withdrawal symptoms at appointments
Craving, preoccupation with
use, compulsive use
1. Recurring requests for increases in opioids
1. Increasing pain despite lack of progression of disease
2. Dismisses nonopioid treatments
3. Focuses on medications and not on other activities
Use despite negative
Consequences
1. Significant side effects, such as sedation and cognitive impairment
2. Overdose
3. Decreases in activity, functioning, and/or relationships


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Table 7. Behavioral Patterns that Suggest Addiction versus Therapeutic use103
Pattern may suggest addiction Pattern suggests therapeutic use
Adverse consequences/harm due to use
Intoxicated, somnolent, sedated
Declining activity
Irritable, anxious, labile mood
Increasing sleep disturbance
Increasing pain complaints
Increasing relationship dysfunction
Favorable therapeutic response use
No significantly altered consciousness
Stable or improving activity
Stable or improved mood
Stable or improved sleep
Stable or improving pain
Improving relationships
Impaired Control over use/Compulsive use
Reports lost or stolen prescription
Frequent early refills
Urgent calls or unscheduled visits
Abusing other drugs or alcohol
Cannot produce medications on request
Withdrawal noted at clinic visits
Observers report overuse or sporadic use
Able to use as prescribed
Rare or no medication incidents
Uses medications as prescribed
Doses discussed at clinic visits
No alcohol or unauthorized drug use
Has expected amount of medication left
No withdrawal signs
Observers report appropriate use
Preoccupation with use due to craving
Frequently misses appointments unless
opioid renewal expected
Does not try nonopioid treatments
Cannot tolerate most medications
Requests medications with high reward
No relief with anything except opioids
Seeking pain relief not opioid reward
Makes most appointments
Shows up for recommended evaluations
Gives reasonable treatment recommendations a fair
trial
Medication sensitivities and favorable responses not
predictable by medication abuse liability
Adopts self-management strategies

Suggested Discussion with Patient when Referring to Pain Medicine or Addiction
Specialist
1. If a clinician is considering referring a patient from primary care to a pain specialist or
addiction medicine, the referring clinician should anticipate the patient’s potential distress
regarding the referral and adequately prepare the patient.5 It is recommended that the
clinician do the following when discussing the referral with the patient104 (UW Health Very low
quality evidence, strong recommendation):
a. Reassure the patient that you are not abandoning him/her and that pain service
involvement likely will be time-limited.
b. Explain that the lack of improvement suggests that the current treatment approach is
not effectively managing the patient’s pain treatment goals.
c. Describe the decision in terms of risk/benefit. Be clear and explain to the patient that
the referral is in the interest of safety and not a judgment of the patient.
d. Reinforce commitment to work with the patient.
2. If the referral is related to ineffective drug therapy or escalating opioid therapy, it is
recommended that the referring provider do the following104 (UW Health Very low quality
evidence, weak/conditional recommendation):
a. Describe/list the specific behaviors that have led to the determination that the risk is
too great to continue.
b. Avoid language such as, “I am not comfortable prescribing these medications for you
anymore.” This type of language can be confusing since it is the patient who is in
discomfort and distress. Consider stating instead, “I am committed to helping you in
any way I can that is safe, but I have determined, due to (list behaviors), that it is no
longer safe to continue to prescribe you these medications because they do not
appear to be effectively improving your function” and reaffirm that the risk-benefit
analysis to assess patient and treatment is the reason for the referral.
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UW Health Implementation
Potential Benefits:
ξ Pain control and management
ξ Improved function and quality of life
ξ Patient engagement
Potential Harms:
ξ Opioid addiction or overdose
ξ Opioid withdrawal
ξ Burden on access to Specialty services (e.g., Pain Clinic)
Pertinent UW Health Policies & Procedures
1. UW Health Policy # 3.5.5- Pain Management
2. UW Health Policy # 1.2.3- Opiate Management
3. UW Health Policy # 3.2.2- Use of the Controlled Substance Alert Within the Medical Record
4. UW Health Policy # 1.2.6- No Further Service
5. UWHC Departmental Policy #8.02- Assessment and Reassessment of Patients and
Documentation in Clinics
6. UWHC Departmental Policy # 2.02- Ambulatory Nursing Staff Roles and Responsibilities
Patient Resources
1. Health Facts For You #5298- Coping with Chronic Pain
2. Health Facts For You #7716- Opioid Medicine for Chronic Pain
3. Health Facts For You #5769- Healing Touch
4. Health Facts For You #4448- How to Relieve Pain
5. Health Facts For You #5761- Managing a Pain Flare
6. Health Facts For You #7934- Pain and the Brain: How the Brain Affects the Pain We
Feel
7. Health Facts For You #4922- Pain Management
8. Health Facts For You #6754- Pain Management During and After Your Emergency
Department Visit
9. Health Facts For You #5641- Fibromyalgia
10. CDC: Opioid Fact Sheet
11. CDC: Promoting Safer and More Effective Pain Management
Guideline Metrics
1. Percent of UW Health chronic pain registry patients on opioids
a. % of patients on opioid therapy > 50 MME
b. % of patients on opioid therapy > 90 MME
c. % of patients on opioid therapy > 300 MME
2. Rate of electronic consults to pain specialist from primary care provider.
Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.
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Clinical Practice Guidelines
Diagnosis and Management of Osteoarthritis – Adult – Ambulatory
Diagnosing and Treating Depression – Adult/Pediatric - Ambulatory
Delegation Protocols
Naloxone Rescue Kit for Opioid Overdose – Adult – Ambulatory [126]
Pain Management Profile Urine Drug Testing – Adult – Ambulatory [115]
Forms
Controlled Substances Medication Agreement
Controlled Substances Medication Agreement- Spanish
Order Sets & Smart Sets
Chronic Pain Management [3195]
Opioid/Narcotic Withdrawal & Addiction [5393]
Urine Drug Testing – Pain Management Delegation Protocol – Adult – Ambulatory [5404]
Fibromyalgia [3053]
Back Pain [94]
Questionnaires
DIRE Score
Brief Pain Inventory
Physical Functional Ability Questionnaire (FAQ5)
Miscellaneous
Chronic Pain Activity
Synopsis Report
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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Appendix A. Evidence Grading Scheme(s)

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.

ACIP GRADE Framework used by the CDC1,3
Evidence Type
1 Randomized clinical trials or overwhelming evidence from observational studies. One can
be very confident that the true effect lies close to that of the estimate of the effect.
2 Randomized clinical trials with important limitations, or exceptionally strong evidence
from observational studies. The true effect is likely to be close to the estimate of the
effect, but there is a possibility that it is substantially different.
3 Observational studies or randomized clinical trials with notable limitations. Confidence in
the effect estimate is limited and the true effect might be substantially different from the
estimate of the effect.
4 Clinical experience and observations, observational studies with important limitations, or
randomized clinical trials with several major limitations. One has very little confidence in
the effect estimate, and the true effect is likely to be substantially different from the
estimate of the effect.
Evidence Category
A Recommendations apply to all persons in a specified group and indicate that most
patients should receive the recommended course of action.
B Recommendations indicated that there should be individual decision making; different
choices will be appropriate for different patients, so clinicians must help patients arrive at
a decision consistent with patient values and preferences, and specific clinical situations.



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Considerations for Shared Decision Making Conversations with Patients
with Chronic Pain1,3
ξ Be explicit and realistic about expected benefits of opioids, explaining that while opioids can
reduce pain during short-term use, there is no good evidence that opioids improve pain or
function with long-term use, and that complete relief of pain is unlikely.
ξ Emphasize improvement in function as a primary goal and that function can improve even
when pain is still present.
ξ Advise patients about serious adverse effects of opioids, including potentially fatal
respiratory depression and development of a potentially serious lifelong opioid use disorder
that can cause distress and inability to fulfill major role obligations.
ξ Advise patients about common effects of opioids, such as constipation, dry mouth, nausea,
vomiting, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms
when stopping opioids. To prevent constipation associated with opioid use, advise patients
to increase hydration and fiber intake and to maintain or increase physical activity. Stool
softeners or laxatives might be needed.
ξ Discuss effects that opioids might have on ability to safely operate a vehicle, particularly
when opioids are initiated, when dosages are increased, or when other central nervous
system depressants, such as benzodiazepines or alcohol, are used concurrently.
ξ Discuss increased risks for opioid use disorder, respiratory depression, and death at higher
dosages, along with the importance of taking only the amount of opioids prescribed, i.e., not
taking more opioids or taking them more often.
ξ Review increased risks for respiratory depression when opioids are taken with
benzodiazepines, other sedatives, alcohol, illicit drugs such as heroin, or other opioids.
ξ Discuss risks to household members and other individuals if opioids are intentionally or
unintentionally shared with others for whom they are not prescribed, including the possibility
that others might experience overdose at the same or at lower dosage than prescribed for
the patient, and that young children are susceptible to unintentional ingestion. Discuss
storage of opioids in a secure, preferably locked location and options for safe disposal of
unused opioids.105
ξ Discuss the importance of periodic reassessment to ensure that opioids are helping to meet
patient goals and to allow opportunities for opioid discontinuation and consideration of
additional nonpharmacologic or nonopioid pharmacologic treatment options if opioids are
not effective or are harmful.
ξ Discuss planned use of precautions to reduce risks, including use of prescription drug
monitoring program information and urine drug screening. Consider including discussion of
naloxone use for overdose reversal.
ξ Consider whether cognitive limitations might interfere with management of opioid therapy
(for older adults in particular) and, if so, determine whether a caregiver can responsibly co-
manage medication therapy. Discuss the importance of reassessing safer medication use
with both the patient and caregiver.
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