Chronic Pain

  1. In a patient with chronic pain:
    1. Establish the etiology
    2. Reassess and periodically review the etiology (e.g., previously undisclosed abuse, evolution of the underlying cause)
    3. Periodically look for potential comorbidities or complications, particularly mental illness and addictions
  2. In a patient with chronic pain who complains of significantly increased pain, search for an alternative etiology (e.g., malignancy, addiction, diversion) as you cannot assume that the original cause of the pain is the reason for the exacerbation.
  3. In a patient in whom you did not make the initial diagnosis of chronic pain:
    1. Establish an effective relationship
    2. Verify the diagnosis
    3. Clarify goals of treatment and plans for management
  4. In managing a patient with chronic pain:
    1. Use shared decision-making
    2. Engage other professionals in this care when appropriate
  5. In a patient with chronic pain:
    1. Comprehensively document the assessment, plan, goals, and prescription details
    2. Make the treatment plan appropriately accessible (e.g., to the patient, team members, emergency department, on-call doctors, pharmacy)
  6. When prescribing medications with abuse potential in a patient with chronic pain where you have no established relationship or insufficient records, be prudent in your prescribing (e.g., limit doses, document reasons, check for double doctoring). Do not simply provide or refuse to prescribe.
  7. Use a written treatment contract with realistic consequences (e.g., limiting prescribed quantities/carries) when prescribing medications with abuse potential to a patient with chronic pain.
  8. When a patient with chronic pain has breached a contract:
    1. Manage your own emotions
    2. Address the possible impact on your staff and team
    3. Apply or judiciously amend the contract (e.g., not putting a patient into immediate withdrawal)
  9. In a patient with chronic pain and addiction who presents with a destabilization of behaviour, carefully identify the etiology and contributing factors to adapt your management plan.