Chronic Pain Guidelines Outline Best Practices

In an effort to assist primary care physicians in assessment and management of patients with chronic non-cancer pain, the Medical Society of Wisconsin in 2004 issued new guidelines after more than two years of review of "best practices" and current research.

The guidelines not only help physicians and non-physician clinicians in their day-to-day practice, said Robert E. Kettler, MD, Medical College of Wisconsin Associate Professor of Anesthesiology, they're also part of the movement toward "evidence-based" standards that rely on large-scale research results to improve outcomes for individual patients. Dr. Kettler practices at the Froedtert & The Medical College of Wisconsin Pain Management Center.

"The American Society of Anesthesiologists has also produced a number of what they call 'practice parameters' for both acute and chronic pain," said Dr. Kettler. "I think that the biggest value of the Medical Society guidelines, particularly for something like chronic pain, is when you have a complicated medical problem. It's difficult for an individual physician to keep up with all the current research and know both what is valid and what also can have a meaningful impact on one's practice.

"If guidelines are put together correctly, you can have an organization review that literature and come up with what seem to be good practices so the individual physician has a template that they can follow. Depending on how they've been set up, guidelines don't really tie the physician's hands.

"If physicians find that the clinical situation doesn't quite fit the guidelines, they usually have a fair amount of freedom to make the decisions that they and the patient see fit. The guidelines really bring together all the information on a complicated problem in a way that an individual physician really can't. I think the Medical Society did a good job of that with these guidelines."

Initial Evaluation to "SMART" Treatment
From the first physician evaluation of a patient's pain to setting treatment goals using the SMART (specific, measurable, achievable, realistic, time based) method to assessing outcomes and follow-up, the guidelines offer a lot of information in a document that is easy to read and sprinkled with charts, graphs, and sample questionnaires used to determine medical history and level of pain.

Based on the most up-to-date research available, the document discusses a variety of medications, therapies, interventional and surgical approaches and other topics directed at health care professionals, written in refreshingly clear language. The guidelines outline new concepts in pain management that are being put into practice at a rapid pace, and in Dr. Kettler's view the document itself is an important step forward.

"I think the biggest change from ten years ago is that you have something like this to begin with," said Dr. Kettler. "Establishing practice parameters like that is a recent development in and of itself, is an important one, and I think is one that is very good. There is a fair amount of material on managing chronic pain with opioids, and that has always been a controversial topic and still is. Setting out some guidelines for using them is something that we didn't really do ten years ago. The guidelines may make it more acceptable as well as more effective."

Opioids - narcotics including morphine, codeine, and related medications - are commonly prescribed because of their effective analgesic, or pain relieving, properties. Studies have shown that properly managed medical use of opioid analgesic compounds is safe and rarely causes addiction. Taken exactly as prescribed, opioids can be used to manage pain effectively.

"Another thing that I thought was relatively new in these guidelines is the portion on setting treatment goals, what they should be and how to go about doing that (the SMART approach). Although we often unconsciously think that we have to have treatment goals, a lot of the time treatment goals aren't very clear. If you don't have clear goals, sometimes you'll find that you're not really providing the treatment you should. The guidelines make it explicit that you should set therapeutic goals. I thought the SMART acronym was a very nice way to do that; it gives a good way to remember the important attributes of a goal."

Evidence-Based Standards
By using a "station to station" overall thematic design, the Medical Society guidelines progress smoothly from "point A" to "points B, C and D," etc., which is important to Dr. Kettler and others in the field of pain assessment and treatment. They also reflect the newer way of looking at things in medicine in general, which is to apply standards based on more hard, scientifically gathered and reviewed evidence than in the past.

"These guidelines will assist physicians and non-physician clinicians in their daily practice," said Dr. Kettler. "They will help establish some clear goals for therapy. They then give a good overall way to assess the patient, which to some extent is reiterating the complete medical history and physical and that's good for people to remember.

"And then they lay out a 'stepwise' approach, where you start with relatively simple measures at first and then can move on to more complicated measures if the simple measures don't seem to work. They take into account new developments. For example, bed rest for a week or more used to be the common standard for chronic lower back pain. Now we're getting those patients much more active much sooner.

"In the past, much of pain management was based on anecdotal evidence. A physician might provide a particular form of therapy and publish the results or tell colleagues if it worked out. We now know that therapy should be based on results in studies done in many patients. This provides the best chance of providing the care appropriate for the most patients."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.