1. Diagnosis. Identify causes of chronic pain through appropriate imaging, electromyography, and other testing. Identifying the pathophysiology for the pain supports the use of opiate therapy.
2. Psychological assessment, including risk of addictive disorders. Assess for depression, as some patients tend to cope with depression or anxiety by using opiates. Nontreatment of depression makes it very difficult to obtain adequate pain relief. Screen for patient/family history of any substance abuse. This does not rule out chronic opiate therapy, but does raise the level of risk and may indicate need for referral to a pain/addiction specialist.
3. Informed consent. Discuss the risks and benefits of chronic opiate therapy, including side effects and risk of addiction. There is also a risk that the pain may not respond to the opiates, and they may need to be discontinued if pain and function does not improve. Patient and provider should sign an agreement that specifically addresses these points prior to starting opiate therapy.
4. Treatment agreement. Also called a narcotic contract, this specifies the conditions under which opiate therapy will be continued or discontinued. Typically, the patient agrees to obtain prescriptions for opiates through one provider, take only the prescribed amount, undergo random urine drug testing, and abstain from use of illicit substances or alcohol with the prescribed drug. Both the patient and the provider should retain a copy of the agreement.
5. Pre and post intervention assessment of pain level and function. Document pain scores and level of function at baseline before opiates are started. A set of simple questions such as "Are you able to complete your job duties/household chores/self care activities?" can be rated on a 1 to 10 scale and reassessed during treatment, along with a pain score, to support continuation of therapy with improved function.
6. Appropriate trial of opioid therapy with or without adjunctive medication. Antidepressants, muscle relaxants, neuropathic medications, and anti-inflammatory medications can improve the response to opioids. Titrate the opiate dose to obtain pain relief and minimize side effects. If there is no improvement in pain and function, the medication should be titrated back down and discontinued.
7. Reassessment of pain score and level of function. This should be completed at each visit and used as the basis for continuation or adjustment of therapy.
8. Regularly assess the "4 As" of pain medicine. Routine assessment of Analgesia, Activity, Adverse effects, and Aberrant behaviors will support the current therapy and alert the provider to problems with medication use. Aberrant behaviors range from low risk (associated with inadequate pain relief) to high risk (more associated with substance abuse).
9. Periodically review pain diagnosis and other conditions, including possible addiction disorders. Repeat diagnostic procedures at appropriate intervals to look for worsening or improving pathology. Assess for new disease process. Reassess for underlying addiction disorder, especially if aberrant behaviors are present.
10. Documentation. Careful recording of the initial evaluation and each follow-up is necessary to protect the clinician and the patient. Documentation that a standard approach to chronic pain management has been followed can reduce malpractice risk and risk of regulatory sanction.