Why is abnormally high dosing often required when medications are used to manage pain? For many patients in pain, their nervous system has undergone “plastification” as a result of the pain. Functional MRI often shows multiple areas of the brain with abnormal function. Be it the development of tolerance with opioids or the higher doses of non-opioid medications required to deactivate abnormal synaptic transmissions, patients with chronic pain often require dosing higher than what may be considered therapeutic for other conditions. These higher doses should not lead to suspicion of misuse or drug dependency but should lead to careful evaluation to identify possible adverse effects.

Providing Support

In chronic-pain patients who have been properly screened for addiction risk using the Opioid Risk Tool (see Table 1), the risk of addiction for those who are scored at low risk is less than 0.2 percent—60 times lower than the general public rate of addiction. When these patients arrive in our emergency departments, they do not know where else to turn. Simply saying “no” is not a solution. Guiding them to support services, advising them of community resources, demonstrating understanding, and educating them on the role of the emergency department in their care are all key roles for emergency physicians to play. We advise smokers to stop smoking and guide them to programs; we encourage alcoholics to get into detox programs; we advise diabetics about diet, exercise, and community programs—surely, we can do the same for patients with chronic pain.

Higher than normal dosing carries a higher risk of adverse events. Another example of risk is seen in patients prescribed methadone for pain or addiction. These patients will have a markedly prolonged QT interval from the methadone. Multiple case reports of sudden death have been reported after patients taking methadone were prescribed a fluoroquinolone.

Mandate for Care

Caring for patients with chronic pain is part of the emergency department mandate. Distinguishing them from patients with problems of addiction is difficult, but they are not the same patients and should not be treated similarly. They have very different needs because they suffer from very different pathologies. Learning more about chronic pain conditions will allow us to provide the necessary care.

Hands On: Chronic-Pain Management at McKesson Canada

As part of my role within McKesson, I directly oversee the running of nine community-based pain centers where patients with chronic non-cancer pain are treated. Unlike what is commonly thought, only one-third of the patients treated there received opioids as part of their care. The optimal approach to chronic-pain management is a combination of multidisciplinary clinical care, self-management programs to learn proper coping skills, medications, and nerve blocks (the last is effective in roughly 20 percent of all chronic-pain patients). Identifying patients with pain at risk for addiction is a key screening element and part of a 21-page initial evaluation tool completed by patients. In those patients identified as “at risk,” care pathways without opioids or with methadone are explored. Patient agreements are routine and include limiting patients to a single prescriber of opioids, no early renewals, and random urine drug testing (frequency determined by their score on the Opioid Risk Tool). All physicians have to undergo our standard training and be supervised for their first year of practice (provincial regulation) in pain management.