When beginning treatment for chronic pain, an evaluation needs to be conducted to document that the patient has one or more medical conditions indicating that the use of opioids is medically necessary.
Such an evaluation must include an assessment of the patient’s pain and should include documentation detailing the onset of the pain, location of the pain, duration of the patient’s pain, character of the pain, what aggravates the patient’s pain, what relieves the patient’s pain, and the timing of the pain (i.e., morning, afternoon, evening). There should be a discussion as to past treatments and/or medications and the success rates of those medications.
An opioid risk tool should be utilized to assess the patient’s personal and family history of alcohol or substance abuse, and to evaluate the patient’s risk for substance abuse. The opioid risk tool should be included in the patient’s medical records.
Part of the evaluation must be the development of a treatment plan and treatment goals. Some examples of goals include decreasing pain and increasing function, improving pain-associated effects (sleeping issues, depression, anxiety, etc.), screen for treatment side effects, and avoiding unnecessary or excessive medication.
The development of a treatment plan and goals should be completed as early in the process as possible. It needs to be clearly stated and individualized to the patient, such that the patient understands and supports the course of therapy. This plan needs to be updated throughout the course of treatment, so that it continues to be appropriate and realistic.
A treatment plan may require the consultation of, or referral to, other providers, such as addiction specialists or mental health providers. Where appropriate, a treatment plan should include non-drug therapy, such as physical therapy or chiropractic treatment.
There is more skepticism surrounding when opioid therapy should be the sole mode of treatment. If there are justifiable reasons why opioid therapy is the only treatment — such as cost, other treatments having failed, or this really is the best way to treat the pain — they should be documented in the record and supported with additional documentation.
If a patient reports that physical therapy has been attempted and was unsuccessful, a physician should obtain those records, review them, and include them in the patient’s medical file. If, due to a patient’s age and/or condition, physical therapy or interventional procedures would be inappropriate, that also should be documented.
The treatment plan should include an end strategy for treatment. An end strategy should consider whether:
- The underlying pain has improved or resolved;
- Intolerable side effects are present;
- There has been inadequate pain relief;
- The recommended treatment has failed to improve the patient’s quality of life;
- The patient has failed to adhere to a treatment agreement; or
- The patient has presented serious aberrant behavior.