Management of Noncancer Chronic Pain (2018)

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 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills (Dowell, Haegerich, & Chou, 2016). According to the U.S. Surgeon General, “every day in America, 41 people die from a prescription opioid overdose” (Murthy, 2016). The opioid epidemic has emerged as one of our nation’s most urgent public health threats. This prescription drug epidemic and concern for patient safety combined with limited evidence regarding long-term benefits of opioids 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 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 considered.

Chronic pain should be addressed in a manner similar to other chronic medical conditions: It should be recognized as a multifactorial, complex entity and evaluated and managed relying on national guidelines adapted 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.