Position Statements

Management of Chronic Pain

Introduction
The National Commission on Correctional Health Care recognizes the importance of evaluating and managing patients with chronic pain in correctional settings. The management of chronic pain is different from the management of acute pain. Likewise, end-of-life treatment of painful conditions is managed differently than noncancer chronic pain. This position statement addresses noncancer chronic pain in correctional environments.

In the community, pressure to eliminate chronic pain that is noncancer in origin has led to the escalation in prescribing of potent opioid medications with a corresponding epidemic in prescription drug abuse and related deaths during the past decade (Centers for Disease Control and Prevention [CDC], 2010). The majority of opioid overdoses occur among young men with a history of substance abuse who obtained diverted prescription medications (CDC, 2010). This prescription drug epidemic and concern for patient safety combined with limited evidence regarding long-term benefits of opioids has prompted the White House Office of National Drug Control Policy (2011) to call for mandated training of physicians who prescribe opioids. For the same reasons, experts now recommend "smarter, more responsible practices," declaring that "long-term opioid therapy carries too many risks to justify use without improvements in health status" (McLellan & Turner, 2010).

Because complaints of chronic pain are common in corrections, corrections clinicians must address the challenges presented. The use of adjunctive medications such as opiates or GABA analogues is particularly troublesome in the correctional environment because a very high percentage of inmates have a history of substance abuse, chemical dependency, and misuse of prescription medications. In-facility diversion and sales of these "desirable" medications are a potential problem. Every time a prescription is written for one of these medications, patient risk must be considered.

On the other hand, the confinement environment provides opportunities to obtain information (e.g., a patient’s physical activities in the housing unit, at recreation, and at work) that can be important when assessing function and when reviewing the efficacy of treatment. In addition, the availability of directly observed therapy may help in mitigating risk.

Therefore, when patient function remains poor and pain is not well controlled, and other options have been exhausted, a therapeutic trial of medication, including opioids, should be available.

Chronic pain should be addressed in a manner similar to other chronic medical conditions: It should be recognized as a distinct entity and evaluated and managed relying on national guidelines modified for correctional use. Clinicians should not approach the treatment of chronic pain as a decision regarding the use or nonuse of opioids (as in acute pain). Rather, clinicians should consider all aspects of the problem and all available proven modalities.

Clinicians should learn to recognize and interpret chronic pain findings through observation, history taking, physical examination, and reports from others who have an opportunity to observe the patient’s function.

As with any chronic medical problem, treatment plans—including specific quantifiable treatment goals and regularly scheduled follow-up visits—should be established. Treatment goals related to improving or maintaining function are as important as reducing the chronic pain. Depression, substance abuse, and other mental health comorbidities should be evaluated and treated in the overall treatment plan.

Complex chronic care patients are common in the correctional environment. Although consultation should be available with mental health clinicians and pain management specialists—particularly those who may help with palliative procedures—primary care providers must develop the expertise to manage inmates’ chronic noncancer pain. For this reason, correctional clinicians should attain, as necessary, additional training in assessment, management, and the science of chronic pain.

Position Statement

1.     Chronic pain is a distinct clinical entity, requiring an understanding of pain mechanisms, evaluation, and treatment options.

2.     Because a fundamental knowledge of the correctional health care environment and their patients is needed, properly trained primary care clinicians are uniquely qualified to treat chronic pain in correctional settings.

3.     Medical directors and other responsible health authorities should facilitate and encourage appropriate training covering the requisite skills to make reliable diagnoses, establish appropriate treatment plans, and monitor progress for patients with chronic noncancer pain.

4.     Nationally recognized guidelines regarding the care and treatment of chronic pain should be referenced and adapted to the correctional environment.

5.     Chronic pain should be addressed like other chronic medical conditions, in a systematic, objective, structured manner beginning with diagnosis and treatment planning and proceeding with structured and regular monitoring of progress.

6.     Clinicians should establish measurable treatment goals for chronic pain and measure progress against them. Treatment goals should be discussed with the patient but determined by the clinician. They must be functional in nature, measured against the patient’s established baseline, and monitored. The elimination of chronic pain is usually not a realistic goal. Patient expectations must be addressed early. Patient self-report may not be completely reliable but should be included in the assessment.

7.     Most chronic pain can be managed through primary care clinicians. However, an interdisciplinary team approach is often beneficial, and specialty care, including pain management, should be available for patients whose function and chronic pain are not improved with treatment and for patients requiring end-of-life care.

8.     Accepted and evidence-based therapeutic options should be available when medically necessary. A multifaceted and biopsychosocial approach is optimal when possible. Policies banning opioids should be eschewed.

9.     Medication use should be judicious. Benefits and risks for the patient (including abuse) and the facility (potential for diversion) must be considered, recognizing that problems with substance abuse, chemical dependency, and management of prescription medications are common in correctional populations.

10.  Continuity of care planning is important, including consideration of resources and reentry into the community. Care coordination should be ensured to avoid interruption in pain treatment.

Adopted by the National Commission on Correctional Health Care Board of Directors
October 16, 2011.

Acknowledgment
NCCHC thanks the Society of Correctional Physicians for its contributions to the development of this position statement.

References

Centers for Disease Control and Prevention. (August 20, 2010). QuickStats: Number of poisoning deaths involving opioid analgesics and other drugs or substances – United States, 1999-2007. Morbidity and Mortality Report, 59(32), 1026.

McLellan, A. T., & Turner, B. (2010). Chronic noncancer pain management and opioid overdose: Time to change prescribing practices [Editorial]. Annals of Internal Medicine, 152, 123-124.

White House Office of National Drug Control Policy. (2011). Epidemic: Responding to America’s prescription drug abuse crisis. Washington, DC: Author. Retrieved from http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf