Pain Management Inter-Agency Task Force: Meeting Materials – Environmental Scan Report

Table of Contents

Executive Summary
1. Introduction
    1.1 Objectives
2. Methods
    2.1 Research
          2.1.1 Research Questions
          2.1.2 Searches
    2.2 Analysis
3. Results
    3.1 Description Identified Best Practices
    3.2 Clinical Best Practices
          3.2.1 Approaches to Pain Management
          3.2.2 Medication
          3.2.3 Physical Therapy
          3.2.4 Psychological Approaches
          3.2.5 Surgical and Minimally Invasive Procedures
          3.2.6 Complementary and Alternative Medicine
          3.2.7 Other Considerations of Importance
    3.3 Policy Best Practices
          3.3.1 Risk Assessment and Mitigation
          3.3.2 Patient Education
          3.3.3 Provider Education
          3.3.4 Access to Care
          3.3.5 Medication-Assisted Treatment Access
          3.3.6 Provision of Naloxone
          3.3.7 Parity Laws
          3.3.8 Illicit Fentanyl Detection
          3.3.9 Stigma
Acronyms
References
Appendix A: Research Literature Search
Appendix B: Stakeholder Organizations Search
Appendix C: Conferences Search
Appendix D: State and Local Search
Appendix E: Clinical Best Practices Analysis
Footnotes

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Executive Summary

Pain management is a complex, multidisciplinary field consisting of a variety of syndromes present in both the acute and chronic phases. In recent years, a dramatic increase in deaths from opioid overdose and other harms related to prescribing opioids for pain management has led clinical experts and policy analysts to acknowledge the need to examine clinical practices in pain management. Factors related to provider and patient education, risk stratification, service delivery coverage, and increasing stigma have further complicated the use of opioids for the treatment of pain and imposed challenges upon clinical management of acute and chronic pain. The Comprehensive Addiction and Recovery Act (CARA) calls for a coordinated response, including the establishment of an interagency task force to: (1) identify best practices for chronic and acute pain management and the prescription of pain medication (2) identify gaps and inconsistencies in current practices and (3) identify ways to best disseminate this information.

This Environmental Scan (ES) Report informs the Pain Management Task Force (PMTF) established by CARA and provides a brief overview of many clinical best practices and guidelines (CBPs), including those developed by medical associations and federal, state, and local government organizations for management of acute and chronic pain. The ES Report reviews pain management treatment approaches and provides the PMTF with a basis by which to address questions specified in part by CARA legislation. An initial set of questions for PMTF to consider include:

1. What are existing clinical best practices for management of acute and chronic pain developed by medical professional associations and the federal, state, and local governments?
2. What are existing knowledge gaps and inconsistencies across identified clinical best practices?
3. How do existing clinical best practices inform guidance on specific topics specified by the CARA language, including:
   1. Pharmacological, non-pharmacological, and medical device alternatives to opioids to reduce opioid monotherapy in appropriate cases
   2. Optimizing treatments based on differences within and between classes of opioids
   3. Opioids with abuse deterrent technology
   4. Management of high-risk populations who receive opioids in the course of medical care, other than for pain management
4. How do non-clinical (i.e., policy-related) best practices advance and support best practices for management of acute and chronic pain?

The ES Report identifies 38 CBPs, which include clinical recommendations among biopsychosocial and multidisciplinary approaches to pain management, including medication; physical therapy; psychological approaches; surgical and minimally invasive procedures; and complementary and alternative medicine (Question 1). The ES Report describes CBPs relevant to pain management topics that can inform the existence of gaps or inconsistencies across best practices (Question 2), including four topics specified by CARA legislation. First, CBPs recommend multiple pharmacological and non-pharmacological alternatives (including medical devices, as well as complementary and alternative medicine approaches) to opioids (Question 3a). Second, CBPs do not make definitive recommendations about optimizing treatments based on differences within and between classes of opioids (Question 3b). Third, CBPs suggest that abuse-deterrent technologies can be partially effective in the prevention of opioid abuse or misuse and should be used as part of a multifaceted-approach (Question 3c). Fourth, CBPs provide recommendations for management of high-risk populations, including prioritization of non-opioid interventions, consideration of abuse deterrent technology, medication-assisted treatment, provision of naloxone, and prioritization of non-pharmacological treatments (Question 3d). Finally, policy best practices facilitate the execution of CBPs and support other areas of pain management, including risk assessment and mitigation; patient education; provider education; access to care; medication-assisted treatment; provision of naloxone; parity laws; fentanyl detection; and stigma (Question 4). Further analysis of best practices identified by the ES or by the PMTF during future working group discussion may reveal gaps and inconsistencies that could inform development of more effective best practices for providers and policy makers.

1. Introduction

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP, 2017). Pain is a universal experience with profound physical, emotional, and societal costs within our nation (Institute of Medicine, 2011; National Academies of Sciences, Engineering, and Medicine, 2017). The clinical management of pain is a complex, multidisciplinary challenge that has changed significantly in recent decades. In the 1990s, pain management experts began to recognize the issue of inadequate treatment of individuals with pain, leading in part to recognition of pain as a “fifth vital sign,” which many health care organizations adopted in an effort to improve assessment and treatment of pain (Mularski et al., 2006). Clinical guidelines recommending the use of opioids as medication-based treatment began to emerge (Haddox et al., 1997) and marketing of opioid formulations (National Academies, 2017) coincided with a shift in pain management practices towards increased prescription of opioids for pain. Between 2007 and 2012, opioid prescriptions per capita increased 7.3 percent with an estimated 259 million prescriptions written for opioid pain medication in 2012 (Paulozzi, Mack, Hockenberry, and Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, 2014).

Contemporary pain management has been further challenged in recent years, as the US has experienced a dramatic increase in deaths from opioid overdose, substance use disorders, and other harms related to prescribing opioids for pain management (National Academies, 2017). The Centers for Disease Control and Prevention (CDC) estimated that the total number of deaths due to prescription opioids nearly doubled between 1999 and 2011 (NCHS, 2016). Additionally, the CDC estimated that opioids were involved in 61 percent of the 47,055 drug overdose deaths occurring in 2014 (Rudd, 2016). Several other factors have further complicated the use of opioids for the treatment of pain, including stigma associated with opioid use, mental health challenges, substance use disorders, a fragmented health care delivery system, and poor access to evidence-based treatment services (National Academies, 2017).

In 2016, the Comprehensive Addiction and Recovery Act (CARA) was signed into law; it seeks to “address the opioid epidemic, encompassing all six pillars necessary for such a coordinated response – prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal” (Comprehensive Addiction and Recovery Act, 2016). One provision of CARA is to establish “an interagency task force, led by the Department of Health and Human Services (HHS), in conjunction with the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the White House Office of National Drug Control Policy (ONDCP). The Task Force is mandated to develop a set of best practices for chronic and acute pain management and prescribing pain medication.” The CARA legislation further instructs the task force to “determine whether there are gaps in or inconsistencies between best practices for pain management.”  The CARA-mandated task force includes non-federal members that encompass a broad range of stakeholders.

1.1  Objectives

This Environmental Scan (ES) Report informs the Pain Management Task Force (PMTF) established by CARA in the identification of best practices for pain management. The ES Report provides a brief overview of clinical best practices (CBPs) published since 2012 that include recommendations developed by medical associations, as well as federal, state and local government organizations, for management of acute and chronic pain. The ES Report, by design, is not an exhaustive review. The ES Report can be used to establish a common understanding across topics and provides the PMTF with a basis by which to address specific research questions specified in part by CARA legislation.

2.  Methods

The methods of this ES Report (see Figure 2) include three phases designed to collect, identify, and describe CBPs and policy-related best practices across specific pain management topic areas (see Table 1). Phase I (Research) includes defining the research questions of the ES Report, as well as development and execution of searches to collect best practices. Phase II (Analysis) identifies which best practices addressed specific pain management topic areas, as determined by the research questions and discussion with HHS. Phase III (Description) includes development of this Draft ES Report.

2.1 Research

The research processes supporting the ES Report are designed to identify and collect best practices informing pain management and opioid prescription. For the purposes of this ES Report, CBPs are defined as formal clinical practice guidelines (CPGs) or systematic reviews that include clinical recommendations. Specific steps of the research process include the development of research questions, defining search methods, conducting literature searches, and the collection and organization of identified documents.

2.1.1 Research Questions

Based on language from CARA and discussions with HHS PMTF officials, the ES Report is designed to aid the PMTF in addressing the following research questions:

1. What are existing clinical best practices for management of acute and chronic pain developed by the federal, state and local governments, and medical professional associations?
2. What are existing knowledge gaps and inconsistencies across identified clinical best practices?
3. How do existing clinical best practices inform guidance on specific topics specified by the Comprehensive Addiction and Recovery Act (CARA) language, including:
   1. Pharmacological, non-pharmacological, and medical device alternatives to opioids to reduce opioid monotherapy in appropriate cases
   2. Optimizing treatments based on differences within and between classes of opioids
   3. Opioids with abuse deterrent technology
   4. Management of high-risk populations who receive opioids in the course of medical care, other than for pain management
4. How do non-clinical (i.e., policy-related) best practices advance and support clinical best practices for management of acute and chronic pain?

2.1.2 Searches

The ES Report includes four search activities that identify and collect best practices relevant to the research questions and relevant pain management topic areas.

2.1.2.1 Search A: Research Literature

The ES Report includes a search of research literature to identify CBPs published in scientific and medical journals since 2012 that inform the research questions and identified pain management topic areas. The research literature examination consists of a PubMed search using defined search terms (see Appendix A) to identify additional best practices and publications describing background, development, effectiveness and/or impact of best practices.

2.1.2.2 Search B: Stakeholder Organizations

The ES Report includes a search for CBPs disseminated by pain management stakeholder organization using a Google search for websites of pain management stakeholder organizations to identify best practices developed, disseminated, or endorsed by these organizations since 2012 (Appendix B). In addition to federal stakeholder organizations, the search targeted non-federal organizations, including private-sector, non-profit, and medical associations (Appendix B).

2.1.2.3 Search C: Conferences

The ES Report includes a Google search for pain management conference websites (Appendix C) to identify best practices or publications describing background, development, effectiveness, and/or impact of best practices disseminated from 2012 to present.

2.1.2.4 Search D: State-by-State and Local

The ES Report includes a Google search of selected state and local websites (Appendix D) for clinical or policy best practices developed, disseminated, or published since 2012.

2.2 Analysis

The ES Report identifies CBPs addressing specific topics within multidisciplinary treatment areas, including medication, physical therapy, psychological approaches, surgical and minimally-invasive procedures, complementary and alternative medicine approaches, and other considerations. Each CBP was reviewed for language addressing or stating clinical recommendations about 17 topic areas (see Table 1). Text excerpts from CBPs are copied into or summarized in the CBP Analysis Table (see Appendix E) for review. Individual topic areas are reviewed across CBPs to identify high-level patterns, gaps, and/or inconsistencies. The ES Report also reviews identified policy best practice documents to summarize how policy recommendations and actions support existing clinical recommendations identified as CBPs.

3. Results

Results of the ES Report begin with a description of identified best practices. The Clinical Best Practices section describes CBPs across pain management topic areas. Within the clinical section, subsections that describe each topic area are divided into three paragraphs that: 1) introduce the topic, 2) describe CBPs that address the topic, and 3) describe ongoing research or research needs associated with the topic. The Policy Best Practices section provides an overview of policy best practices that support CBPs and other aspects of pain management.

3.1 Description Identified Best Practices

The ES Report identifies 38 CBP documents that vary across focus area of recommendations, pain type, and population. Some CBP documents address pain management, while others focus specifically on opioid prescribing within pain management. Some CBP documents address adult populations, while some were focused on subpopulations including elderly adults, HIV-positive patients, or US military service members and veterans. Some CBPs also focus on specific subtypes of pain, including back pain, intraoperative and perioperative pain, neuropathic pain, and cancer pain. It’s also noteworthy that some CBPs are based upon other CBPs identified by this search. Three CBPs (Oregon Health Authority, 2017; Tehama County Health Services Agency, 2017; West Virginia Board of Pharmacy, 2016) are adapted from a 2016 CBP developed by CDC (Dowell, Haegerich, and Chou, 2016). CBPs developed by New Mexico (New Mexico Department of Health, 2011) and Oklahoma (Oklahoma Board of Nursing and Oklahoma Society of Interventional Pain Physicians, 2013) are adapted from a CBP developed by Utah (Utah Department of Health, 2009).

Table 1: Clinical Best Practice (CBP) Analysis

Pain Management Topic Area	Arnsteen 2017	Bruce 2017	Colorado 2017	Cornelius 2017	Horgas 2017	Manchikanti 2017	Munzing 2017	New Jersey 2017	Oregon 2017	Qaseem 2017	Tehama 2017	VA/DoD 2017	Cooney 2016	Chou 2016	Deng 2016	Dowell 2016	Erie 2016	Paice 2016	West Virginia 2016	Bhatnagar 2015	Kampman 2015	Mai 2015	Marin 2015	Monterey 2015	Washington 2015	Chou 2014	Hegmann 2014	North Carolina 2014	Oklahoma 2013	ASA 2012	Hawaii 2012	San Diego 2012	New Mexico 2011	ASA and ASRA 2010	Chou 2009	Fine 2009	Utah 2009	Wheeling-Ohio [N/A]
3.2.2 Medication
3.2.2.1 Optimizing treatments based on differences within and between classes of opioids (CARA)	X	X																								X
3.2.2.2 Opioids with abuse deterrent technology (CARA)						X																						X					X
3.2.2.3 Pharmacological alternatives to opioids to reduce opioid monotherapy in appropriate cases (CARA)	X	X	X	X	X	X	X			X		X	X	X	X	X		X		X	X	X			X		X	X	X		X			X
3.2.2.4 Medication-Assisted Treatment				X					X	X		X					X					X				X	X						X
3.2.2.5 Co-prescription of benzodiazepines							X		X		X	X		X		X	X	X	X			X	X					X										X
3.2.2.6 Naloxone				X			X		X	X		X								X				X					X	X
3.2.3 Physical Therapy
3.2.3.1 Traditional Physical Therapy	X	X			X	X						X				X	X	X				X			X			X	X				X	X
3.2.3.2 Functional restoration			X			X										X		X				X						X
3.2.4 Psychological
3.2.4.1 Traditional Psychological Interventions	X	X		X	X	X	X				X		X	X				X				X			X			X					X	X	X
3.2.4.2 Self-Management				X		X							X												X
3.2.5 Surgical and Minimally Invasive Procedures
3.2.5.1 Ultrasound guided blocks for acute pain							X						X	X				X		X										X	X			X
3.2.5.2 Neuromodulation					X	X	X						X	X				X		X							X							X
3.2.6 Complementary and Alternative Medicine (CARA)	X		X	X	X		X	X	X	X	X	X		X		X	X		X	X		X			X			X		X	X		X	X			X	X
3.2.6.1 Acupuncture	X	X		X	X								X	X			X	X										X					X	X
3.2.7 Other Considerations
3.2.7.1 Patient Engagement
3.2.7.1.1 Discussion of goals and expectations		X	X	X	X	X	X		X	X	X		X	X		X	X		X	X			X		X	X		X	X	X	X		X		X		X	X
3.2.7.2 Risk Assessment and Mitigation
3.2.7.2.1 Screening and Monitoring	X	X	X	X	X	X	X		X		X	X	X	X		X	X	X	X	X	X	X	X	X		X	X	X	X	X	X	X	X	X	X		X	X
3.2.7.2.2 Management of high-risk populations who receive opioids in the course of medical care, other than for pain management (CARA)													X				X

Key: "X" Indicates topic/subtopic addressed by clinical best practice (CBP)

3.2 Clinical Best Practices

Clinical guidelines can play an important role in pain management. These guidelines therefore also and affect opioid prescription in the current environment of patient risks associated with opioid misuse (National Academies, 2017). Clinical practice guidelines are designed to provide evidence-based information and assist in clinical decision-making to optimize patient care and outcomes. Several recent guidelines for chronic pain management agree on specific recommendations for mitigating opioid-related risk, including upper dosing thresholds, consideration of drug-drug interactions with specific medications and drug–disease interactions, and risk assessment and mitigation (e.g., patient-provider treatment agreements, drug screening/testing; Nuckols et al., 2014). To continue improving pain management in the current environment of opioid-related risks, experts have noted the need to increase the use of guidelines from the CBP as indicated in the specific patients, and access to effective pain management treatments through improvement and adoption of clinical guidelines (Gereau et al., 2014).

However, pain management experts have also identified specific research gaps impeding the improvement of pain management guidelines, as well as other needs, including synthesizing and tailoring recommendations across guidelines, types of pain, and populations. Additionally, there are gaps and inconsistencies within and between pain management and opioid prescribing guidelines (Weinberg and Baer, 2017). This is also due to a difference in demographics as the CPB are often in various aspects of the country. A recent review of clinical opioid prescribing guidelines by Barth, Guille, McCauley, and Brady (2017) notes several research needs, including improved for post-operative pain management, as well as evaluation of the implementation and impact of guideline recommendations on patient risk and outcomes. In light of these research gaps, there are potential limitations to evidence-based clinical recommendations that should be considered by pain management providers (Carr, 2017).

In 2016, in response to growing concerns with overprescribing opioids for pain management and opioid-related overdose, CDC published a widely-read guideline on opioid therapy for chronic pain (Dowell and Haegerich, 2016; Dowell et al., 2016). Despite some strengths of the guideline acknowledged by the medical community, responses to this publication illustrate research opportunities and challenges associated with the development of pain management guidelines. For example, the American Medical Association (AMA) stated that it “supports many of the recommendations” and also raised some concerns including the quality of evidence used to support clinical recommendations (AMA, 2016). McBride (2016) noted that the 2016 CDC guideline did not apply to pediatric populations. A commentary by Busse, Juurlink, and Guyatt (2016) identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. Deren (2016) noted that in addition to addressing limitations of the CDC guideline, changes in patient and payor expectations are needed to change pain management approaches. Noting that the CDC guideline focuses primarily on patients initiating opioid treatment, Gordon and Connolly (2017) discussed application of the guideline to patients who are already receiving opioid maintenance therapy for chronic pain.

Additionally, reviews of guidelines across different types of pain have raised research questions and identified other needs to improve the application of guidelines to pain management and opioid prescription. A systematic review of CPGs for neuropathic pain by Deng et al. (2016) identified shortcomings across four evaluation domains including stakeholder involvement (i.e., extent to which guideline was developed by the appropriate stakeholders and represents the views of its intended users), rigor of development (i.e., process used to gather and synthesize the evidence, as well as the methods to formulate the recommendations), applicability (i.e., likely barriers and facilitators to implementation, strategies to improve uptake, and resource implications of applying the guideline), and editorial independence (i.e., bias in formulation of recommendations). Identified inconsistencies across guidelines for fibromyalgia have demonstrated a need for consensus guideline development (Thieme, Mathys, and Turk, 2017). A review of state-level guidelines for opioid prescriptions found that a minority of states had guidelines specific to emergency departments (Broida, Gronowski, Kalnow, Little, and Lloyd, 2017). Pain guidelines from the World Health Organization are facing a lack of adoption, potentially due to a lack of incorporating contemporary pain management practices (Carlson, 2016).

3.2.1 Approaches to Pain Management

The management of chronic and complex pain syndromes is supported by the biopsychosocial model, which views pain though a holistic lens that takes in to consideration the biological, psychological, and social aspects of diagnosis and treatment (Gatchel, McGeary, McGeary, & Lippe, 2014; Gatchel, Peng, Peters, Fuchs, & Turk, 2007). Coupling the biopsychosocial model with multidisciplinary and interdisciplinary approaches yields the best treatment for patients with pain (IOM, 2011). HHS has developed a National Pain Strategy that “recommends a population-based, biopsychosocial approach to pain care that is grounded in scientific evidence, integrated, multimodal, and interdisciplinary, while tailored to an individual patient’s needs” (HHS, 2016). Recent clinical practice guidelines developed by VA and DoD integrate the biopsychosocial model of pain (VA and DoD, 2017), as the Veterans Health Administration (VHA) has identified biopsychosocial care plans as an essential element to effective pain management (Gallagher, 2016). The biopsychosocial approach is applied clinically across pain experiences, including chronic pain (Cheatle, 2016),and specifically to musculoskeletal pain (Booth et al., 2017), low-back back pain (Kamper et al., 2015; Marin et al., 2017), and HIV-related pain (Bruce et al., 2017).

To reflect multidisciplinary approaches and the biopsychosocial model, this section describing clinical best practices is organized by five major approaches to pain management: medication, physical therapy, psychological approaches, surgical and minimally-invasive procedures, complementary and alternative medicine (CAM) interventions, and other clinical recommendations that span across these multidisciplinary approaches. This report also describes CBPs that can be applied across these five approaches. The following sections identify CBPs that address specific aspects of pain management and opioid prescription.

3.2.2 Medication

The subsections below describe CBPs addressing medication approaches for pain management such as optimizing treatments based on differences within and between classes of opioids; opioids with abuse deterrent technology; pharmacological alternatives to opioids; medication-assisted treatment; co-prescription of benzodiazepines; and naloxone.

3.2.2.1 Optimizing treatments based on differences within and between classes of opioids

Dose and duration of opioid prescriptions for pain management are influential factors in the potential development of addiction (Wardhan and Chelly, 2017). CDC has estimated that 61 percent of overdose deaths in 2014 involved an opioid (Rudd, 2016). Optimizing opioid treatment may be effective in reducing treatment length and dosing regimens, decreasing side-effect burden, and enhancing effective pain treatment with reduced potential for addiction (Arnstein, Herr, and Butcher, 2017).

The ES Report did not identify CBPs that directly address optimizing treatments based on differences within and between classes of opioids; however, some related strategies were mentioned. These include utilizing newer weak opioid analgesics (e.g., tramadol, tapentadol, buprenorphine) that do not rely on liver enzyme production of active metabolites and in turn are better tolerated (Arnstein et al., 2017) versus first-line opioid analgesics (e.g., codeine, hydrocodone); prescribing a combination of short- and long-acting opioid analgesics for additive effects and reducing dosing regimens (e.g., morphine and gabapentin for neuropathic pain) (Bruce et al., 2017); and rotating opioids to achieve a better functional outcome and/or reduce adverse effects with opioid therapy, although no substantive published evidence exists to support this strategy (Hegmann et al., 2014). These observations may reflect existing gaps in the understanding of opioid combinations between classes of opioids and their potential additive, synergistic, and antagonistic therapeutic effects.

Currently, there is little evidence describing the adverse effects, therapeutic efficacy, and risk-benefit of opioid combination (Chou et al., 2015; Peng, Zhang, Meng, Liu, and Ji, 2017). While opioids are indicated for selective use in patients with acute and postoperative pain, there is a dearth of quality evidence indicating that opioid analgesic therapy is superior to non-opioid analgesic therapy for improving pain and function (Hegmann et al., 2014). Experts have noted that before addressing opioid optimization, the superiority of opioid analgesic therapy over other approaches needs to be demonstrated (Arnstein et al., 2017; Hegmann et al., 2014). Additionally, better understanding of patient profiles is needed to predict which patients can safely be prescribed opioids without dose escalation (Naliboff et al., 2011).

3.2.2.2 Opioids with abuse-deterrent technology

Improvements in abuse-deterrent technologies are being developed with the goal of preventing alterations of prescription opioid formulations and the extraction of the active ingredient by users (FDA, 2017). For example, some abuse-deterrent formulations (ADF) have a hardened tablet surface that prevents crushing, while others turn into a gooey substance upon crushing – both designed to limit the potential for injecting the core substance. ADFs also include adding a pharmaceutical or chemical compound to the opioid to decrease the user’s response to the abused substance or provide an adverse reaction when the medication is altered. To address misuse and abuse of prescription opioids, the U.S. Food and Drug Administration (FDA) released guidance in 2015 for the development of opioids formulated to meaningfully deter abuse (FDA, 2015). A challenge to the development of opioid ADFs is the need to maintain the same safety and efficacy profile as the opioid without ADF for FDA approval (FDA, 2016; Moorman-Li et al., 2012).

Three CBPs address opioids with abuse-deterrent technology to prevent opioid abuse and reduce adverse effects (Manchikanti et al., 2017). All CBPs acknowledge that ADF opioids, alone, are not sufficient to prevent opioid abuse or misuse and recommend a multifaceted-approach combining ADF opioids with risk evaluation and mitigation strategies (REMS) and prescription drug monitoring and overdose prevention programs as a comprehensive opioid risk management approach to reduce opioid abuse and misuse (Manchikanti et al., 2017; New Mexico Department of Health, 2011; North Carolina Medical Board, 2014). One of the three CBPs also recommends the use of sequestered opioid antagonists such as naloxone to pharmacologically deter abuse by rendering the opioid ineffective, as a better approach compared to ADF opioids (Manchikanti et al., 2017).

To date, some evidence exists that ADF opioids have limited effectiveness and result in unintended consequences (Barnett, Gray, Zink, and Jena, 2017). Post-marketing data have demonstrated that introduction of ADF opioids reduced illicit route conversion by at least 45 percent, only marginally reduced oral abuse, and resulted in at least 25 percent of users bypassing the ADF opioid mechanism (Cicero and Ellis, 2015; Coplan et al., 2016; Manchikanti et al., 2017). Studies have also demonstrated that reformulated OxyContin® is associated with increased abuse of other opioids, particularly analgesics that are amenable to tampering (Cicero and Ellis, 2015; Turk, Dansie, Wilson, Moskovitz, and Kim, 2014). However, these studies examine one of several existing ADF approaches and do not address whether patients displaying low- and high-risk of abuse are likely to follow similar courses under ADF opioid treatment. Experts have noted that to further examine the abuse-deterrent potential of an opioid formulation, future research efforts can evaluate abuse liability and likelihood of ADF opioid circumvention and calculate the misuse and abuse in patients displaying both low- and high-risk of abuse (Kaye, Jones, Kaye, Ripoll, Jones, et al., 2017).

3.2.2.3 Pharmacological alternatives to opioids to reduce opioid monotherapy in appropriate cases

Long-term opioid therapy for pain management is significantly associated with increased risk of opioid disorder, overdose, myocardial infarction, and motor vehicle injury in some pain management populations (Dowell et al., 2016). Pharmacological alternatives to opioids for pain management are not associated with substance use disorder; have a fraction of the number of overdoses associated with opioid analgesics; and may be a favorable treatment option to opioid analgesics for pain management (Jones, Mack, and Paulozzi, 2013; Qaseem, Wilt, McLean, Forciea, and Clinical Guidelines Committee of the American College of Physicians, 2017).

Twenty-three CBPs recommend pharmacological alternatives to opioids to reduce opioid monotherapy. Recommendations vary per treatment indication and ranged between non-opioid analgesics to adjuvant analgesics to multimodal approaches for pain management. Fifteen CBPs endorse non-opioid analgesics including over-the-counter medications, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen as a first-line pharmacological alternative for acute, mild-to-moderate, and chronic pain. Although acetaminophen is recommended as the preferred non-opioid agent for treatment of acute and mild-to-moderate pain due to decreased side effects (Bruce et al., 2017; Cornelius, Herr, Gordon, Kretzer, and Butcher, 2017; Horgas, 2017), one CBP argued that acetaminophen showed only a moderate effect of pain relief compared to opioids (Manchikanti et al., 2017). For chronic non-responders, NSAIDs are recommended as first-line of treatment, and tramadol or duloxetine as second-line treatment, prior to consideration of opioids (Qaseem et al., 2017). Furthermore, one CBP recommends a multimodal approach combining pharmaceutical alternatives with ablative techniques, acupuncture, nerve blocks, electrical nerve stimulation, physical therapy, and/or psychological treatment as a holistic strategy for chronic pain management (ASA and ASRA, 2010). High-quality evidence also support the use of NSAIDs, gabapentin, pregabalin, and oral celecoxib as part of a multimodal analgesia treatment course for post-operative pain (Chou, Gordon, et al., 2016; Cooney, 2016). In reference to the treatment of neuropathic conditions, three of the 23 CBPs recommend the use of adjuvant analgesics, including antidepressants and selected anticonvulsants (Horgas, 2017; Manchikanti et al., 2017; Paice et al., 2016); however, these recommendations may be inconsistent. Two CBPs indicated adjuvant analgesics as equally or more effective, and with less risk than opioids for neuropathic pain treatment (Horgas, 2017; Washington, 2015); while another highlighted a minimal effect on improvement compared to opioid agents (Manchikanti et al., 2017). These observations suggest potential variations across clinical recommendations for appropriate alternative approaches to pain management.

Experts have noted that while pharmacological interventional therapies can be effective for pain management, they may be associated with renal, gastrointestinal, and liver disease, rendering them a limited treatment option for long-term use (Dowell et al., 2016; Horgas, 2017). Although a multimodal approach is emphasized as a preferred strategy for combating chronic pain, experts note that further evidence is needed about the effectiveness of and compliance with multimodal alternative treatments for pain management compared to unimodal approaches (Manchikanti et al., 2017).

3.2.2.4 Medication-Assisted Treatment

Opioid use disorders (OUDs) are characterized by compulsive behaviors to self-administer opioids without medical cause or in doses in excess of clinical recommendation (Lagisetty et al., 2017). Medication-assisted treatment (MAT) is the practice of administering an opioid agonist, antagonist, or a combination of the two in conjunction with psychological counseling to help patients with OUD recover (Itzoe and Guarnieri, 2017).

Nine CBPs recommend MAT for patients with OUDs. All CBPs recommend methadone, buprenorphine, naltrexone and/or naloxone in combination with behavioral therapies for patients with OUD after carefully considering the patient’s prior treatment history and treatment setting. One CBP recommends incentivizing private physicians to partner with licensed treatment agencies to increase access to MAT to enhance the odds of successful recovery from opioid dependence (Governor’s Task Force on Drug Abuse Control, 2017). Another CBP recommends the use of the Screening, Brief Intervention, and Referral to Treatment protocol in acute settings to decrease drug abuse and increase follow-up for treatment programs (Colorado Chapter of the American College of Emergency Physicians, 2017). This CBP also recommends initiation of buprenorphine and naloxone as an effective method for transitioning patients into recovery.

Research has shown that primary care-based models for MAT demonstrate equivalent efficacy compared to specialty substance use treatment facilities and that certain populations have an advantage in improving comorbidity outcomes (Lagisetty et al., 2017). Experts have noted that better a understanding of which core implementation structures and components are effective in primary care-based models of MAT would provide a useful basis for expanding access of MAT to OUD treatment (Korthuis et al., 2017; Lagisetty et al., 2017).

3.2.2.5 Co-prescription of benzodiazepines

Benzodiazepines are a class of psychoactive agents that depress central nervous system (CNS) activity and are prescribed to relieve anxiety, panic attacks, and seizures (Day, 2013). Studies have shown that co-prescription of opioid analgesics and benzodiazepines is associated with increased adverse side effects and increased risk of fatal and nonfatal overdose (Gudin, Mogali, Jones, and Comer, 2013; Maree, Marcum, Saghafi, Weiner, and Karp, 2016; Weisberg et al., 2015).

Thirteen CBPs address co-prescription of benzodiazepines with opioid analgesics. Seven CBPs recommend clinicians use caution and avoid, when possible, prescribing opioid analgesics with other medications that cause CNS depression such as benzodiazepines, muscle relaxants, and hypnotics. These cautionary recommendations are based on strong evidence of severe drug-drug interactions, including increased risk of side effects and increased risk of over-sedation in chronic opioid therapy (Marin County Department of Health and Human Services, 2015; West Virginia Board of Pharmacy, 2016). One of the seven CBPs specifically recommends that clinicians discuss these increased risks prior to co-prescribing benzodiazepines and to ensure that treatments for depression and other co-occurring mental health conditions were optimized (Tehama County Health Services Agency, 2017). Five CBPs strongly recommend against the concurrent use of benzodiazepines and opioid analgesics due to the increased risk of overdose and death.

There is evidence supporting the associated risks of co-prescribing benzodiazepines in patients with chronic pain (Dowell et al., 2016), HIV (Weisberg et al., 2015), pulmonary disease (Ekström, Bornefalk-Hermansson, Abernethy, and Currow, 2014) and sleep apnea (Paice et al., 2016). However, experts acknowledge that further research is needed to examine overdose outcomes and elucidate which types and what doses of benzodiazepines increase the risk associated with overdose (Brandt and Leong, 2017).

3.2.2.6 Naloxone

Naloxone is a potential life-saving medication capable of reversing CNS depression associated with opioids and restoring normal breathing in overdosed patients (McDonald and Strang, 2016). It was approved in 1971 by the FDA and has been used to reverse the effects of opioid toxicity with minimal adverse effects (Lewis, Vo, and Fishman, 2017). Although naloxone has historically been administered in emergency settings by trained health care providers, recent efforts are being made widely distribute the agent as a take-home kit for use by individuals with high risk of opioid overdose (Lewis et al., 2017; McDonald and Strang, 2016; Wheeler, Jones, Gilbert, Davidson, and CDC, 2015).

Nine CBPs discuss the use of naloxone for overdose prevention. Seven of the nine CBPs recommend clinicians first evaluate patients for factors that increase risk for opioid overdose. These factors include patients with history of overdose, OUD, high opioid-dose prescription, concurrent pain and depression prescriptions, and gaps in opioid-medication use but currently being placed back on previous opioid dosages (Dowell et al., 2016; Manchikanti et al., 2017; Munzing, 2017). All CBPs recommend co-prescribing naloxone to patients exhibiting risk factors for opioid overdose as a risk mitigation strategy. Support for this recommendation comes from moderate-quality evidence that demonstrates take-home naloxone programs are effective in improving overdose survival with minimal adverse events (VA and DoD, 2017). One of the nine CBPs strongly recommends the use of Suboxone®, a sublingual film containing buprenorphine and naloxone, as the most effective method for transitioning OUD patients into recovery (Colorado Chapter of the American College of Emergency Physicians, 2017). Furthermore, three CBPs emphasize the importance of appropriately training family and caregivers of high-risk patients, as well as first responders, in naloxone administration to reduce opioid-related emergency visits (Health Care Association of New Jersey, 2017; Manchikanti et al., 2017; Marin et al., 2017; VA and DoD, 2017).

Systematic reviews have identified naloxone as a life-saving measure following opioid overdose (McDonald and Strang, 2016; VA and DoD, 2017). McDonald et al. (2016) noted that although clinical efficacy has been established for naloxone used on short-acting opioids (e.g., hydromorphone, oxycodone and codeine), efficacy of intervention from long-acting opioids (e.g., methadone, Oxycontin®, extended-release opioids) is unclear and needs further exploration.

3.2.3 Physical Therapy

Physical therapy is a component of biopsychosocial, multidisciplinary approaches to pain management. The subsections below describe CBPs addressing traditional physical therapy approaches and functional restoration.

3.2.3.1 Traditional Physical Therapy

Physical therapy approaches for pain include therapeutic exercises, manual therapy, application of heating and cooling agents, and ultrasound. Therapeutic exercise can include aerobic exercise, strength training, and flexibility training (Ambrose and Golightly, 2015). Manual therapy includes mobilization and manipulation approaches (Hidalgo, Detrembleur, Hall, Mahaudens, and Nielens, 2014).

Fourteen CBPs discuss physical therapy approaches for pain management. Four CBPs recommend physical therapy among other non-pharmacological treatment as preferred approaches to opioids (Dowell et al., 2016; Erie County Opiate Epidemic Task Force, 2016; Horgas, 2017; VA and DoD, 2017). Two CBPs recommend physical therapy as one component of a multimodal approach (Manchikanti et al., 2017; Washington State Agency Medical Directors’ Group, 2015). Arnstein et al. (2017) cite evidence that physical therapy, massage, and yoga are beneficial for pain and pain-related side effects in older adults.

Researchers are continuing to investigate evidence supporting the use of various physical therapy modalities for application to different types of pain. A recent review found that clinical guidelines supported the use of physical and exercise therapy, manual therapy, massage, and yoga for chronic, non-cancer pain (CADTH, 2016).

3.2.3.2 Functional Restoration

Functional restoration is based on the biopsychosocial model, viewing pain and disability as a complex and dynamic interaction among physiological, psychological, and social factors that perpetuate or worsen the clinical presentation (Gatchel and Mayer, 2008). Functional restoration seeks to address pain through professional, social, functional, and psychological rehabilitation (Poulain et al., 2010). Functional restoration has been compared to individual physical therapy as potentially more effective for improving outcomes such as returning to work (Jousset et al., 2004; Poulain et al., 2010).

Six CBPs discuss assessment and consideration of functional outcomes in determining use of opioids for pain management (Colorado Chapter of the American College of Emergency Physicians, 2017; Dowell et al., 2016; Mai, Franklin, and Tauben, 2015; Manchikanti et al., 2017; North Carolina Medical Board, 2014; Paice et al., 2016). None of these CBPs discuss functional restoration programs specifically. These observations suggest a potential need for additional research to demonstrate benefits of functional restoration programs for incorporation into CBPs.

Experts are continuing to develop functional restoration programs for the treatment of pain. Tavares Figueiredo et al., (2016) established and achieved educational objectives with pain patients as part of a functional restoration program, with a positive effect on return-to-work outcomes at six and 12 months. Military researchers recently demonstrated the potential benefits of including a patient’s significant other in a functional restoration program framework (McGeary et al., 2016). Additionally, investigators have been validating additional measures of function for functional restoration programs (Neblett, Hartzell, et al., 2017; Neblett, Mayer, et al., 2017).

3.2.4 Psychological Approaches

Psychological aspects of pain are a component of diagnosis and treatment within the biopsychosocial and multidisciplinary approaches. The subsections below describe CBPs addressing traditional psychological approaches and self-management of pain.

3.2.4.1 Traditional Psychological Interventions

In recent decades, pain management experts have recognized the role of psychological factors in the experience of pain, and thus the potential for utilizing psychological interventions to manage pain (Manchikanti, Fellows, and Singh, 2002). Psychological interventions for pain include cognitive and behavioral approaches that seek to identify and replace maladaptive cognitive and behavioral responses to pain. These include cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based cognitive therapy (Kaiser, Mooreville, and Kannan, 2015). Another psychological approach is biofeedback, which measures electrophysiological processes so patients and clinicians can monitor and influence physiological and psychological responses to pain (Neblett, 2016). Mindfulness meditation is thought to address pain by enabling patients to reframe experiences by increasing awareness of present surroundings and sensations (Hilton et al., 2017). Psychological interventions are often administered as a component of a multidisciplinary approach and can be coupled with medication, physical therapy, and other treatments.

Sixteen CBPs address psychological assessment or treatment interventions. Two CBPs recommend the use of psychological interventions for chronic pain management (ASA and ASRA, 2010; Paice et al., 2016). Bruce et al. (2017) recommend CBT for chronic pain management in HIV patients. One CBP concludes that existing evidence was insufficient to recommend psychological interventions for acute or subacute low-back pain, however, some low- to moderate-quality evidence supported psychological interventions for chronic low-back pain (Qaseem et al., 2017). Generally, most of the 16 identified CBPs recommend psychological assessment or screening of patients at early stages of management. Nine of the 16 identified CBPs were focused specifically on opioid prescription, however, four of these nine noted that non-pharmacological treatments (specifically psychological, behavioral, or cognitive approaches) should be prioritized over opioids (Dowell et al., 2016; Washington State Agency Medical Directors’ Group, 2015) or coupled with opioid medication (Chou et al., 2009; Manchikanti et al., 2017). One CBP recommends the use of psychosocial approaches in the treatment of addiction involving opioid use (Kampman and Jarvis, 2015).

Experts have identified research needs in the development of guidelines for psychological interventions in pain management. Kaiser et al. (2015) noted that although several psychological approaches have been shown to successfully modify patient responses to pain, a “gold standard” of treatment has yet to emerge. For example, evidence supporting psychological approaches to low back pain are generally of low- to moderate-quality, or published too long ago to be applicable to modern approaches (Reese and Mittag, 2013).

3.2.4.2 Self-Management

Self-management is a CBT-based intervention that challenges emotional and behavioral responses to pain with the goal of improving function, mood, and the experience of pain (Cameron, 2012; Mills, Torrance, and Smith, 2016). Self-management “focuses on the patient’s ability to manage their own condition rather than treatment being based within the health care system or centered on a health care professional” (Nicholl et al., 2017). Self-management approaches, which can be offered as a component of multidisciplinary care, connect patients to print- and internet-based educational resources including interactive digital applications, toolkits, books, magazines, leaflets, videos, and audio recordings (Mills et al., 2016; Nicholl et al., 2017; Schofield, 2014).

Four CBPs address self-management interventions. Consideration of self-management approaches is recommended among non-pharmacological alternatives to opioid therapy (VA and DoD, 2017) or in combination with medical therapy (Washington State Agency Medical Directors’ Group, 2015). One CBP notes that the potential for self-management in older adults with dementia may be limited due to impairment in cognitive capacity (Horgas, 2017).

Experts have noted research needs for the application of self-management interventions for alleviating pain. For example, a systematic review by Nicholl et al. (2017) noted that the evidence base for interactive digital applications supporting self-management of lower back pain is currently weak. Current challenges to self-management for pain include lack of family support, financial barriers, fear of increased activity and poor patient-physician interactions (Bair et al., 2009; Price, Lee, Taylor, Baranowski, and British Pain Society, 2014).

3.2.5 Surgical and Minimally Invasive Procedures

Surgical and minimally-invasive procedures can address root causes and symptoms of pain. These procedures can include nerve blocks (Ilfeld, 2017), epidural steroid injections (House, Barrette, Mattie, and McCormick, 2018), radiofrequency ablation of nerves (Bhatia, Peng, and Cohen, 2016), Botox® injections (Patil et al., 2016), cryotherapy (Sullivan, Lyons, Montgomery, and Quinlan-Colwell, 2016), and capsaicin treatment (Derry, Rice, Cole, Tan, and Moore, 2017). The sections below address ultrasound guided blocks and neuromodulation.

3.2.5.1 Ultrasound guided blocks for acute and chronic pain

In recent years, there has been rapid and widespread adoption of ultrasound guidance techniques that enable physicians to perform targeted insertion of catheters and delivery of injections (e.g., local anesthetics) for improved postoperative pain control efficacy and safety (Mariano, Marshall, Urman, and Kaye, 2014). Ultrasound guidance has become increasingly popular for use in various procedures, including nerve blocks for acute and chronic pain (Hurdle, 2016).

Eight CBPs address nerve blocks for pain, two of which discuss ultrasound-guided nerve blocks specifically. Chou et al. (2016) recommend that clinicians be familiar with ultrasound guidance as a part of a broader recommendation to consider surgical site-specific peripheral nerve block regional anesthetic techniques in adults and children for postoperative pain procedures. For example, Bhatnagar and Gupta (2015) recommend ultrasound-guided celiac plexus block for pancreatic cancer pain. In the emergency care setting, administration of nerve blocks in patients with femoral fractures can decrease subsequent opioid use (Kassam, Gough, Davies, & Yarlagadda, 2018).

Experts continue to assess ultrasound-guided regional anesthesia (Neal et al., 2016), which may also be particularly advantageous for use with young children (Guay, Suresh, & Kopp, 2017). Recent studies have shown that ultrasound-guided nerve blocks reduce postoperative pain opioid analgesic administration (Kim et al., 2016; Qi, Du, Gurnaney, Lu, & Zuo, 2014). Ongoing research needs include development of best practice treatment options that provide information about comparative effectiveness and patient outcomes, as well as evidence describing the efficacy of training strategies such as simulation models (Mariano et al., 2014).

3.2.5.2 Neuromodulation

Neuromodulation techniques utilize device-based electrical or magnetic stimulation techniques to activate central or peripheral nervous system tissue associated with pain pathways to produce analgesia or reduce sensitivity to pain. These electrotherapeutic modalities for pain include spinal cord stimulation for chronic pain (Slavin, 2014; Verrills, Sinclair, and Barnard, 2016), implanted peripheral nerve stimulation for headaches (Reed, 2013), and transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain (Vance, Dailey, Rakel, and Sluka, 2014). Additionally, pulsed electromagnetic field therapy (PEMF) and repetitive magnetic stimulation (rMS) have been applied to neck pain (Kroeling et al., 2013).

Nine CBPs address the application of neuromodulation techniques for pain management. Two CBPs support consideration of neurostimulation as a component of non-pharmacological approaches to pain management (Munzing, 2017; Paice et al., 2016). Two CBPs recommend consideration of TENS as an adjunct to other treatments in postoperative pain (Chou, Gordon, et al., 2016; Cooney, 2016).

Research continues to assess the effectiveness of neuromodulation approaches for multiple types of pain. Preclinical and clinical studies seek a better understanding of spinal cord stimulation while application of the technology has grown quickly in recent years (Chakravarthy, Richter, Christo, Williams, & Guan, 2018; Sdrulla, Guan, & Raja, 2018). Grider et al. (2016) found different levels of evidence supporting the efficacy of spinal cord stimulation for pain associated with failed back surgery syndrome across different simulation parameters (e.g., high-frequency stimulation, adaptive simulation, burst stimulation). Current research suggests that TENS can be effective for postoperative pain, osteoarthritis, painful diabetic neuropathy, and some acute pain conditions (Vance et al., 2014). Existing evidence for the efficacy and clinical usefulness of electrotherapy modalities, including TENS, PEMF, and rMS, for neck pain is generally of low quality, so additional research is needed to make more firm clinical recommendations (Kroeling et al., 2013).

3.2.6 Complementary and Alternative Medicine

Complementary and alternative medicine (CAM) refers to health and wellness approaches not considered to be a part of conventional medicine (Mayo Clinic, 2017). The National Center for Complementary and Integrative Health (NCCIH), formerly known as the National Center for Complementary and Alternative Medicine, defines complementary approaches as those “used together with conventional medicine” and alternative approaches as “used in place of conventional medicine,” noting that most patients who use non-conventional approaches do so in addition to conventional treatments (NCCIH, 2017b). CAM approaches can include acupuncture, dietary/nutritional supplements, massage, yoga, and meditation, and NCCIH recognizes several complementary approaches for pain (NCCIH, 2017a). CBPs generally recommend consideration or prioritization of non-pharmacological approaches to acute and chronic pain in appropriate patient scenarios (ASA and ASRA, 2010; Bruce et al., 2017; Erie County Opiate Epidemic Task Force, 2016; Horgas, 2017; New Mexico Department of Health, 2011; Paice et al., 2016; Qaseem et al., 2017), which include some CAM approaches such as acupuncture. The subsection below describes CBP recommendations addressing acupuncture.

3.2.6.1 Acupuncture

An estimated three million American adults receive acupuncture each year (Barnes, Bloom, and Nahin, 2008). Acupuncture is most commonly used in chronic pain, with several studies indicating that low-back pain, neck pain, osteoarthritis and knee pain, and migraine headaches were common applications (NCCIH, 2017a). In these cases, acupuncture is known to have physiological effects related to analgesia, but CPGs often debate the evidence-based science and accepted mechanism by which it has persisting effects on chronic pain (Vickers et al., 2012).

Eleven CBPs address acupuncture in the context of pain management. Four CBPs recommend acupuncture among other non-pharmacological approaches that should be applied before or in addition to medication-based interventions (Erie County Opiate Epidemic Task Force, 2016; New Mexico Department of Health, 2011; Paice et al., 2016; Qaseem et al., 2017). Three CBPs generally recommend consideration of acupuncture for pain management (ASA and ASRA, 2010; Bruce et al., 2017; North Carolina Medical Board, 2014). Two CBPs cite evidence that acupuncture can alleviate pain (Cornelius et al., 2017; Horgas, 2017). Two CBPs indicate that existing evidence is insufficient to recommend for or against acupuncture for postoperative pain management (Chou, Gordon, et al., 2016; Cooney, 2016).

Recent reviews and meta-analyses show that acupuncture can reduce pain. A review of randomized control trials concludes that acupuncture is beneficial for low back pain and osteoarthritis of the knee (Nahin, Boineau, Khalsa, Stussman, and Weber, 2016). Cho et al., (2014) examined 13 CPGs and 22 systematic reviews and meta-analyses (SR-MAs) to investigate gaps between traditional medicine interventions of East Asian countries (acupuncture) and current CPGs. The authors conclude that current CPGs underestimate the effectiveness of traditional medicine manual therapy, especially for chronic low back pain. The authors supported a “moderate” recommendation of acupuncture for chronic low back pain and noted that existing evidence was inconclusive to recommend acupuncture for subacute low back pain. A meta-analysis across 29 randomized controlled trails by Vickers et al. (2012) indicated that acupuncture is associated with more potent placebo or contextual effects compared to other CAM interventions. The authors conclude that acupuncture is effective for the treatment of chronic pain and therefore a reasonable referral option. Despite this research, experts have noted that existing studies have not transformed clinical attitudes about acupuncture for pain (Harris, Lifshitz, and Raz, 2015).

3.2.7 Other Considerations of Importance

Some CBPs can potentially be applied across the five multidisciplinary and biopsychosocial treatment approaches discussed above. The sections below describe CBPs addressing patient engagement (including patient-provider discussion of goal and expectations) and risk assessment and mitigation (including screening and monitoring), as well as management of high-risk populations.

3.2.7.1 Patient Engagement

Experts have recognized the need to improve patient-provider communication in pain management (Frantsve and Kerns, 2007). Patient engagement approaches are a component of more effective patient-provider communication, enabling patients to actively participate in management of their pain experience and improve outcomes. Patient engagement approaches include formalized discussions between patients and providers about goals, expectations and risks of treatment, and documented contracts or agreements between patient and provider. Education materials can also engage patients by providing information about pain management tools and resources (Washington State Agency Medical Directors’ Group, 2015), as well as instructions for proper storage and/or disposal of opioid medication to prevent non-medical usage of prescriptions (Hawaii Chapter of the American College of Emergency Physicians, 2012; Marin County Department of Health and Human Services, 2015; New Mexico Department of Health, 2011; Oklahoma Board of Nursing and Oklahoma Society of Interventional Pain Physicians, 2013; Utah Department of Health, 2009). The subsection below describes CBPs addressing patient-provider discussion of goals and expectations.

3.2.7.1.1 Discussion of goals and expectations

Establishing goals and expectations can help patients understand potential treatment outcomes of pain relief and improvement in function, enabling a joint decision between patient and physician on initiation of opioid therapy (Manchikanti et al., 2017). A common understanding between patient and provider can be documented in a patient-provider contract, which is a written, formalized agreement detailing the responsibilities of both participants in the treatment process with opioids and controlled substances (Albrecht et al., 2015).

Twenty-six CBPs address discussions between physician and patients about the use of opioids for pain. Eight CBPs recommend discussion between provider and patient about goals, benefits, expectations, and/or risks of opioid therapy (Chou et al., 2014; Dowell et al., 2016; Erie County Opiate Epidemic Task Force, 2016; Manchikanti et al., 2017; Qaseem et al., 2017; Tehama County Health Services Agency, 2017), with some recommending that clinicians provide this information to the patient’s primary caregiver or guardian (North Carolina Medical Board, 2014; Oregon Health Authority, 2017). Four CBPs recommend inclusion of a written patient-provider agreement documenting goals, benefits, expectations, and/or risks before initiating opioid treatment for pain (Chou et al., 2014; Manchikanti et al., 2017; Oklahoma Board of Nursing and Oklahoma Society of Interventional Pain Physicians, 2013; West Virginia Board of Pharmacy, 2016).

Research needs remain regarding how patient-provider communication can enhance pain management. A review by Geurts et al. (2017) concludes that better informing patients about pain management treatment processes could help to increase patient satisfaction. Additionally, perceptions about effectiveness and legal status of patient-provider agreements need to be addressed with additional research and patient-centered design of agreement documentation (Albrecht et al., 2015).

3.2.7.2 Risk Assessment and Mitigation

Despite known risks of opioid use disorders, some patients do not develop these problems following prescription of opioid analgesics for pain. Therefore, it is important to conduct risk stratification for patient populations. There is a significant need for identifying and mitigating risks of opioid misuse and diversion (Kaye, Jones, Kaye, Ripoll, Galan, et al., 2017). Risk assessment approaches seek to identify patients at the early stages of the pain management processes and follow them across the treatment process should additional interventions be needed to optimize treatment and avert opioid misuse. The subsections below describe CBPs addressing screening and monitoring, as well as management of high-risk populations.

3.2.7.2.1 Screening and Monitoring

Screening and monitoring in pain management seeks to identify and reduce the risk of opioid misuse and addiction, as well as improve overall patient care. Screening and monitoring approaches include screening tools, assessment of patient physical and psychological history, urine testing, and prescription drug monitoring programs (PDMPs). These approaches seek to enable providers to identify high-risk patients in order for them to consider substance misuse interventions, ADFs, and education materials to mitigate opioid misuse (Kaye, Jones, Kaye, Ripoll, Jones, et al., 2017).

Thirty-three CBPs address screening and monitoring. Most of these CBPs recommend that clinicians screen patient history for substance use and/or conduct thorough physical and psychological evaluations to screen for risk factors and characterize pain to inform treatment. Thirteen CBPs recommend preliminary or random urine drug testing. Nine CBPs recommend that clinicians check PDMPs when prescribing opioid medication (Dowell et al., 2016; Erie County Opiate Epidemic Task Force, 2016; Hegmann et al., 2014; Horgas, 2017; Mai et al., 2015; Manchikanti et al., 2017; Munzing, 2017; Tehama County Health Services Agency, 2017; VA and DoD, 2017).

Although experts note there are some limitations in evidence assessing the impact of conducting a patient history on pain outcomes (ASA and ASRA, 2010; Hegmann et al., 2014), a comprehensive history (including physical examination) in addition to screening and monitoring is generally recommended. Tailoring these approaches to patient needs will be necessary, as there is a lack of screening and monitoring tools that can be applied universally across all pain scenarios (Solanki, Koyyalagunta, Shah, Silverman, and Manchikanti, 2011). Additionally, there is no single tool capable of reliably and accurately predicting which patients need increased abuse monitoring or are unsuitable for opioid therapy (Kaye, Jones, Kaye, Ripoll, Galan, et al., 2017).

3.2.7.2.2 Management of high-risk populations who receive opioids in the course of medical care, other than for pain management

Given the risk of opioid misuse and abuse, it is important to consider how best to treat pain in individuals at high risk of addiction. Patients taking opioids are at increased risk of opioid use disorder, opioid overdose, and other adverse outcomes (National Academies, 2017). Additionally, there are concerns about how to treat post-operative pain in patients with substance abuse and/or opioid use disorders (Barth et al., 2017).

CPGs identified by the ES Report address several components of pain management in patients at high risk of addiction, including prioritization of non-opioid interventions (see Section 3.2.2.3), consideration of abuse deterrent technology (see Section 3.2.2.2), medication- assisted treatment (Section 3.2.2.4), provision of naloxone (Section 3.2.2.6), and prioritization of non-pharmacological treatments (Section 3.2.6). One CBP focused specifically on clinical recommendations for treatment of addiction involving opioid use (Kampman and Jarvis, 2015). An overall multimodal approach depending on the type of surgery or procedure is recommended (HHS, 2016).

3.3 Policy Best Practices

Policy recommendations can support clinical recommendations identified through CBP guidance by identifying legislative or other actions that can provide resources and eliminating barriers to enable improved pain management. Many policy activities also support non-clinical needs relevant to pain management in the current environment of opioids and associated risks. The sections below provide an overview of policy best practices informing risk assessment and mitigation; patient education; provider education; access to care; medication-assisted treatment; provision of naloxone; parity laws; fentanyl detection; and stigma.

3.3.1 Risk Assessment and Mitigation

Several government and stakeholder organizations have made policy recommendations or taken specific policy actions to enable providers to assess and mitigate patient risks associated with pain management medication. For example, Colorado, West Virginia and Washington support screening patients for prior history of substance use at the early stages of treatment (Colorado Chapter of the American College of Emergency Physicians, 2017; Washington State Agency Medical Directors’ Group, 2015; West Virginia Board of Pharmacy, 2016). Additionally, both New Jersey and Maine have recommend an increase in early intervention screenings at schools for youths that are at-risk for SUDs (Delahanty III, Mills, and Morris, 2016; Governor’s Task Force on Drug Abuse Control, 2017). The Connecticut Opioid REsponse (CORE) initiative has supported partnership development between treatment programs and clinicians who provide screening and referral, and has also developed emergency department-based programs for screening, brief intervention, and treatment initiation with buprenorphine (Connecticut, 2016). States have also supported early or random urine testing to identify at-risk patients (Arizona Department of Health Services, 2017; Oregon Health Authority, 2017), and Pennsylvania is currently investigating methods for more precise detection and determination of alcohol and controlled substances in urine and blood samples (Pennsylvania, 2015). Rhode Island encourages the standardized use of urine-drug testing to screen for benzodiazepine/opioid co-ingestion for opioid treatment programs (Rhode Island, 2015). The utility of written patient-provider agreements has also been recognized at the state level (West Virginia Board of Pharmacy, 2016).

The need to modernize and provide adequate funding for PDMPs is widely acknowledged (AMA, 2015; Carrizosa and Latham, 2017; Massachusetts Department of Public Health, 2015; South Dakota Department of Health, 2017). Provider PDMP adoption has shown to be reduced when interoperability is low and use isn’t mandated (Barnett et al., 2017). Colorado favors the integration of automatic queries and responses that obviate time-consuming manual data entry, and also recommends that PDMPs be optimized with improvements such as automatic queries, links to emergency department registration, and data population in electronic medical records (Colorado Chapter of the American College of Emergency Physicians, 2017). Maryland also recommends enhanced user interfaces and interstate data sharing for PDMPs (Carrizosa and Latham, 2017).

As discussed below (3.3.2 and 3.3.3), policy actions and recommendations to enhance physician and patient education resources can help mitigate risks of abuse and diversion.

3.3.2 Patient Education

Patient education resources can complement pain management strategies by strengthening patient understanding of opioid risk and benefits, and are critical components of self-management treatment approaches (see Section 3.2.4.2). Patient education resources include toolkits, books, magazines, leaflets, videos, and audio recordings (SAMHSA, 2016; Washington State Agency Medical Directors’ Group, 2015).

Stakeholder organizations and individual states have recognized the benefits of educating patients and surrogates about the known risks and realistic benefits of treatment prior to initiating opioid therapy (Colorado Chapter of the American College of Emergency Physicians, 2017; Governor’s Task Force on Drug Abuse Control, 2017; Massachusetts Department of Public Health, 2015; North Carolina Medical Board, 2014; Oregon Health Authority, 2017; Tehama County Health Services Agency, 2017). Local elected leaders have implemented traditional methods of resource dissemination, such as town hall meetings and pamphlets, but are now also exploring newer platforms such as Facebook and Twitter to reach out to their constituents (NACo-NLC, 2016). Mass-media campaigns have been seen in both the private and public sectors; for example, New Jersey has implemented a campaign around preventing opioid addiction by launching a help hotline and website, and the Partnership for Drug-Free Kids has worked with private-sector partners such as Google to run public service announcements that inform parents about available help for their loved ones (President’s Commission on Combating Drug Addiction and the Opioid Crisis, 2017a). Several stakeholders have also published opioid-overdose toolkits and guidelines that provide patients and family members with opioid safety advice, general recommendations, and additional resources for overdose prevention (SAMHSA, 2016; Washington State Agency Medical Directors’ Group, 2015).

3.3.3 Provider Education

Health care professionals who prescribe opioids are in a key position to balance the benefits of analgesics against the risk of adverse clinical outcomes. It is estimated that “apart from federal prescribers who are required to be trained, fewer than 20% of the over one million prescribers licensed to prescribe controlled substances to patients have training on how to prescribe opioids safely” (President’s Commission on Combating Drug Addiction and the Opioid Crisis, 2017b). Health care providers can access educational resources, receive accreditation, or renew existing licenses through public- or private-sector enterprises (Carrizosa and Latham, 2017). Stakeholders have recommended that accrediting organizations develop, review, promulgate, and regularly update core competencies for pain care education and licensure and certification at the pre-licensure (undergraduate) and post-licensure (graduate) levels (HHS, 2016; NACo-NLC, 2016).

Stakeholder organizations and individual states have recognized the benefits of additional provider education resources (Dowell et al., 2016; Massachusetts Department of Public Health, 2015; Oregon Health Authority, 2015; SAMHSA and OSG, 2016). Released in 2017, the President’s Commission on Combating Drug Addiction and the Opioid Crisis recommends mandating medical education training in opioid prescribing and risks of developing substance abuse disorder (President’s Commission on Combating Drug Addiction and the Opioid Crisis, 2017a). The Presidential Commission also recommends development of national training standards and provision of training courses coordinated between government organizations and the medical community. The National Pain Strategy recommends development of a pain education portal to provide standardized education materials applicable to the continuum of pain (HHS, 2016).

3.3.4 Access to Care

Chronic pain affects as many as 100 million Americans (National Academies, 2017), many of whom face significant barriers to accessing medical and other pain management resources (Kampman and Jarvis, 2015; NACCHO, 2016). Several organizations have identified policy recommendations to close gaps in access to pain management services (AAPM, 2014; Pennsylvania, 2015). For example, the American Academy of Pain Medicine recommends developing a program of mandatory insurance benefits to address barriers to treatment for chronic pain (AAPM, 2014).

Given the risk of addiction and OUD in the current environment of pain management, the need to provide greater access to substance abuse services has become clear (Kampman and Jarvis, 2015). An estimated 80 percent of people with an opioid addiction are not receiving treatment for substance use disorders (Saloner and Karthikeyan, 2015). The National Academy of Medicine recommends that states provide universal access to evidence-based treatment for OUD (National Academies, 2017). Several organizations recommend increasing service and delivery capacity for treatment of substance- and opioid-related addiction (AMA, 2015; CMS, 2016; NGA, 2016). One way of increasing treatment capacity could be allowing states to waive the Institutions for Mental Diseases (IMD) exclusion, which prohibits Medicaid reimbursement of substance abuse services provided within inpatient facilities of more than 16 beds (NGA, 2016; President’s Commission on Combating Drug Addiction and the Opioid Crisis, 2017a; WH ONDCP, 2017), or eliminating the IMD exclusion altogether. Individual states have recommended increasing access to substance abuse treatment and resources (California Department of Public Health, 2016; Massachusetts Department of Public Health, 2015; Minnesota Department of Human Services, Alcohol and Drug Abuse Division, 2017), and many states have enacted legislation designed to enhance access to care (National Association of State Alcohol and Drug Abuse Directors, 2015). Additionally, the National Governor’s Association has outlined several policy mechanisms for expanding access to treatment and recovery resources, including allowing nurse practitioners, physician assistants, and medical residents to prescribe buprenorphine for opioid addiction; lifting or eliminating provider caps on the number of patients treated with buprenorphine; and ensuring that providers have access to patients’ substance abuse disorder treatment information (NGA, 2016).

3.3.5 Medication-Assisted Treatment Access

As discussed above (see Section 3.2.2.4), MAT generally includes the usage of methadone, buprenorphine, or naltrexone specifically tailored toward individual patient needs (Massachusetts Department of Public Health, 2015; Rhode Island, 2015).

Several stakeholder organizations have made policy recommendations to increase access to MATs. The American Academy of Pain Medicine recommends and has supported legislative actions that limit inappropriate prescribing, and at the same time, allow patients who suffer from moderate to severe pain to access proper medication (AAPM, 2013). Stakeholders also recommend provider collaboration and increased funding to further enhance MAT through community-service boards, drug-treatment courts, or jail-based treatment (NACo-NLC, 2016; NGA, 2015; ONDCP, 2016). Several local leaders and stakeholder organizations also recommend an expansion of insurance coverage for addiction treatments and a removal of limits on such treatments (NACo-NLC, 2016).

Individual states have identified policy actions designed to increase access to MAT. Minnesota is currently exploring telehealth-supported infrastructure to expand office-based opioid treatment and is pushing for an increased workforce of buprenorphine-waivered prescribers (Minnesota Department of Human Services, Alcohol and Drug Abuse Division, 2017). Rhode Island is further building a capacity for MAT delivery by developing “Centers of Excellence for the Treatment of Opioid Problems” and removing administrative barriers, such as the prior authorization associated with buprenorphine; expanding MAT to new care settings by encouraging cross-institution collaboration and offering MATs for those undergoing detoxification services; and optimizing delivery of MATs in existing care settings by reducing payment barriers to opioid treatment (Rhode Island, 2015). Additionally, several states are advocating for an increase in access to MAT (Governor’s Task Force on Drug Abuse Control, 2017; Massachusetts Department of Public Health, 2015; Pennsylvania Department of Drug and Alcohol Programs, 2015).

3.3.6 Provision of Naloxone

An estimated 50,000 deaths are associated each year with opioid overdose in the US (Rudd, Aleshire, Zibbell, and Gladden, 2016). As discussed above (see Section 3.2.2.6), naloxone can prevent opioid overdose by blocking opiate receptor sites if treatment is initiated as early as possible, even before the arrival of emergency medical services at the scene (SAMHSA, 2016). Improving access to naloxone would enable emergency responders and other providers to administer timely interventions in overdose scenarios and save lives.

Stakeholder organizations and individual states have identified and/or executed policy actions that can increase access to and provision of naloxone. The National Association of State Alcohol and Drug Abuse Directors (NASADAD) has identified 40 states and the District of Columbia that have passed laws to expand the availability of naloxone (NASADAD, 2015). The most common details from those laws include: third-party prescription, standing orders, liability protections, naloxone distribution programs, educational strategies, and over-the-counter naloxone (NASADAD, 2015). Several stakeholders and individual states also recommend developing additional best practice guidance for addiction treatment and distribution of naloxone (NACo-NLC, 2016; New York Heroin and Opioid Task Force, Task Force Heroin and Opioid Task Force, New York, and New York, 2016; NGA, 2016). Pennsylvania is working with lawmakers to allow law enforcement to administer naloxone, and is also working to create continuing medical education on naloxone co-prescribing (Pennsylvania Department of Drug and Alcohol Programs, 2015). Oregon passed a law in 2013 that allowed the establishment of medically-supervised lay-person (non-medical professional) naloxone rescue (Oregon Health Authority, 2015). Additionally, in 2015, the NYC Health Commissioner authorized an order to make naloxone available without a prescription in participating pharmacies (City of New York Office of the Mayor, 2017).

3.3.7 Parity Laws

Parity laws legally recognize mental health conditions and substance abuse as equal to physical illness. The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires group health plans and health insurance companies to guarantee that the financial requirements and treatment limitations for SUD and mental health disorder benefits are no more restrictive than the financial requirements or treatment limitations applied to medical and surgical benefits (ONDCP, 2016).

Ongoing policy and legislative activities in the past two decades have sought to ensure equal clinical attention to SUDs and addiction (NGA, 2015; ONDCP, 2016). In 2008, VA included SUD treatment in the VHA Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics, which details the benefits available to enrollees (ONDCP, 2016). In 2013, DoD expedited changes to the TRICARE policy manuals to allow for the provision of medication-assisted treatment in TRICARE-authorized SUD treatment facilities (ONDCP, 2016). In 2015, HB 1747 was enacted, requiring the State Corporation Commission’s Bureau of Insurance to develop reporting requirements regarding denied claims complaints and appeals involving coverage for behavioral health benefits (NGA, 2015). In 2016, the Centers for Medicare and Medicaid Services (CMS) issued a regulation applying the parity standards to explain how the MHPAEA applies to Medicaid managed-care organizations, Medicaid alternative benefit plans and the Children’s Health Insurance Program benefits (ONDCP, 2016). Several states are enacting policy requirements that further enforce legislative parity laws (Louisiana Commission on Preventing Opioid Abuse, 2016; Massachusetts Department of Public Health, 2015). Arizona is convening an Parity Task Force to research and provide recommendations regarding parity and standardization across the state (Arizona Department of Health Services, 2017).

3.3.8 Illicit Fentanyl Detection

Fentanyl and fentanyl analogues represent a current and emerging threat in the US as a pure illicit narcotic and in mixtures with other substances (ONDCP, 2016). Fentanyl, which has legal medical use in the operating room and in some topical patch applications, may be 50‐100 times more potent than morphine and 30‐50 times more potent than heroin; carfentanil, which is structurally related to fentanyl, is up to 10,000 times more potent than morphine (DEA, 2017; ONDCP, 2016). Due to the dangerous health and abuse risks associated with illicit use of these compounds, policies facilitating rapid and comprehensive detection are needed.

Several stakeholder organizations have worked to curtail fentanyl overdose through various forms of drug testing. CDC recommends that public health departments explore methods for more rapid detection of overdose outbreaks by using existing surveillance systems such as medical examiner data, emergency medical services data, or near real-time emergency department data (CDC National Center for Injury Prevention and Control, 2017). The use of enzyme-linked immunosorbent assay is also recommended to medical examiners and coroners to detect fentanyl (CDC National Center for Injury Prevention and Control, 2017). The US Drug Enforcement Agency is currently evaluating detection devices for use in field-testing for the presence of fentanyl and fentanyl analogues (DEA, 2017). Fentanyl test strips are common and have been distributed by various stakeholder organizations and public health departments (Committee on Energy and Commerce and Subcommittee on Oversight and Investigations, 2017). The National Institute on Drug Abuse (NIDA) has funded the National Drug Early Warning System (NDEWS), which uses multiple sources of data to monitor fentanyl use. NDEWS traces drug use patterns and trends in sentinel communities and across the nation (Committee on Energy and Commerce and Subcommittee on Oversight and Investigations, 2017). NIDA is also funding a study to explore the use of “paper spray” mass spectrometry, which simplifies the testing process, and disposable paper spray cartridges, which automate the preparation of the same for testing (Committee on Energy and Commerce and Subcommittee on Oversight and Investigations, 2017). Private sector initiatives have also invested in updated handheld spectrometers to allow law enforcement officers and customs officials to scan pills, powders, and other various unknown substances (Hiolski, 2017).

3.3.9 Stigma

Stigma remains a significant barrier to implementation of programs and treatments seeking to address opioid-related risks of pain management, including MAT (Chou, Korthuis, et al., 2016; Salsitz and Wiegand, 2016) and naloxone (Winstanley, Clark, Feinberg, and Wilder, 2016). Stigma not only makes individuals less likely to seek treatment, but it also makes marshaling investment more challenging for prevention and treatment programs associated with substance abuse (SAMHSA and OSG, 2016).

Stakeholder organizations and individual states have sought to reduce stigma-associated barriers to prevention and treatment for individuals with substance abuse needs stemming from opioid-based pain management approaches (AMA, 2015; Delahanty III et al., 2016; HHS, 2016; Massachusetts Department of Public Health, 2015; RWJF, 2017). Maine is increasing public awareness by hiring marketing firms to create comprehensive statewide education campaigns, engaging youth in developing messages and social media content, and utilizing the Addicting Technology Transfer Center’s anti-stigma toolkit (Delahanty III et al., 2016). Connecticut is working with media outlets and state agencies to increase the dissemination of accurate, evidence-based, and non-stigmatizing information on the causes, manifestations, and treatments of SUDs (Connecticut, 2016). South Carolina recommends additional education and accurate information about the risks and benefits of treatment to directly tackle bias related to stigma (Governor’s Prescription Drug Abuse Prevention Council, 2014). Massachusetts and California are also creating public awareness campaigns focused on reframing addiction as a medical disease and promoting medication safety practices (California Department of Public Health, 2016; Massachusetts Department of Public Health, 2015). Strong community engagement and advocacy are also necessary to overcome the stigma associated with substance use disorders and behavioral health conditions in order to build support for community-based treatment and expansion of MATs (RWJF, 2017).

Acronyms

Abbreviation	Meaning
ADF	Abuse-deterrent formulations
CAM	Complementary and alternative medicine
CARA	Comprehensive Addiction and Recovery Act
CBP	Clinical best practice
CBT	Cognitive behavioral therapy
CDC	Centers for Disease Control and Prevention
CMS	Centers for Medicare and Medicaid Services
CNS	Central nervous system
CPG	Clinical practice guideline
DoD	Department of Defense
ES	Environmental scan
FDA	Food and Drug Administration
HHS	Department of Health and Human Services
IASP	International Association for the Study of Pain
IMD	Institutions for Mental Diseases
MAT	Medication-assisted treatment
MHPAEA	Mental Health and Addiction Equity Act
NCCIH	National Center for Complementary and Integrative Health
NDEWS	National Drug Early Warning System
NGA	National Governors Association
NIDA	National Institute on Drug Abuse
NSAIDs	Non-steroidal anti-inflammatory drugs
OUD	Opioid use disorders
PDMP	Prescription Drug Monitoring Program
PEMF	Pulsed electromagnetic field therapy
PMTF	Pain Management Task Force
rMS	Repetitive magnetic stimulation
SUD	Substance Use Disorder
TENS	Transcutaneous electrical nerve stimulation
VA	Department of Veterans Affairs
VHA	Veterans Health Administration

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West Virginia Board of Pharmacy. (2016). West Virginia Expert Pain Management Panel Safe & Effective Management of Pain Guidelines 2016. Charleston, WV: Author. Retrieved from http://sempguidelines.org/wp-content/uploads/2016/09/WV-Pain-Management-Guidelines-No-Appendix.pdf

WH ONDCP. (2017). Presidential Commission Interim Report.

Wheeler, E., Jones, T. S., Gilbert, M. K., Davidson, P. J., & CDC. (2015). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014. MMWR. Morbidity and Mortality Weekly Report, 64(23), 631–635.

Winstanley, E. L., Clark, A., Feinberg, J., & Wilder, C. M. (2016). Barriers to implementation of opioid overdose prevention programs in Ohio. Substance Abuse, 37(1), 42–46. https://doi.org/10.1080/08897077.2015.1132294

Appendix A: Research Literature Search

The ES Report includes a search for scientific and medical research literature disseminating CBPs, as well as publications discussing impact and signification of CBPs. The research literature search consists of the following steps:

1. Search strings constructed by combining terms from Columns A, B, and C from Table 2 below
2. Search results narrowed according to search limits below
3. Manual review of resulting article titles and abstracts to identify articles potentially relevant to directly addressing research questions
4. Review of full text articles to determine if relevant to directly addressing research questions
5. Search limits:
   1. Publications directly addressing research questions
   2. English language articles only
   3. Review of articles includes those published since 2012; however, articles published prior to 2012 are included if considered fundamental to understanding the research questions

Table 2: Search Terms

Best Practices (Column A)	Pain Management (Column B)	Interventions (Column C)
clinical guidelines clinical practice guidelines treatment guidelines treatment gaps research gaps	pain treatment pain medicine pain management chronic pain acute pain	pharmacologic non-pharmacologic intervention acupuncture opioid medication assisted treatment medication-assisted treatment methadone buprenorphine naltrexone neuromodulation ultrasound guided blocks nerve blocks biopsychosocial model multidisciplinary functional restoration self-management

Appendix B: Appendix B: Stakeholder Organizations Search

The ES Report includes a search for CBPs disseminated by pain management stakeholder organization using a Google search for websites of pain management stakeholder organizations to identify best practices developed, disseminated, or endorsed by these organizations (Table 3). In addition to federal stakeholder organizations, the search targets non-federal organizations, including private sector, non-profit, and medical associations. Google search terms include names of stakeholder organizations (Table 3) and search terms from Appendix A.

Table 3: Pain Management Stakeholder Organizations

Federal

Non-Federal

Office of National Drug Control Policy (ONDCP) Domestic Policy Council of the United States Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) Agency for Healthcare Research and Quality (AHRQ) Food and Drug Administration (FDA) Centers for Disease Control and Prevention (CDC) National Institutes of Health (NIH) National Institute on Drug Abuse (NIDA) Office of the National Coordinator for Health Information Technology (ONC) Office of the Assistant Secretary for Health (OASH) Office of the Surgeon General Substance Abuse and Mental Health Services Administration (SAMHSA) Pain Management Research Interagency (within NIH) The National Center for Injury Prevention and Control (NCIPC) Board of Scientific Counselors (within CDC)

American Society of Interventional Pain Physicians American Chronic Pain Association American Society of Anesthesiologists American Society of Regional Anesthesia and Pain Medicine American Cancer Society American Academy of Pain Management American Medical Association American College of Medical Toxicology American Pain Society American Academy of Pediatrics American Society of Hematology American College of Obstetrics and Gynecology American Society of Addiction Medicine American Academy of Pain Medicine American Society of Clinical Oncology American Geriatrics Society American Academy of Neurology American Academy of Physical Medicine and Rehabilitation American Society of Interventional Pain Physicians American Hospital Association Physicians for Responsible Opioid Prescribing American Association of Nurse Practitioners American Society of Neurosurgery American College of Surgeons American College of Radiology Society of Clinical Psychology

Appendix C: Appendix C: Conferences Search

The ES Report utilizes a Google search for pain management conference websites (Table 4) to identify best practices or publications describing background, development, effectiveness, and/or impact of best practices disseminated since 2012. Google search terms include names of conferences (Table 4) and search terms from Appendix A.

Table 4: Pain Management Conference Websites

Conference and/or Medical Society	Date
American Society of Anesthesiologists: Annual Meeting	2012 - 2017
American Society of Interventional Pain Physicians: Annual Meeting	2012 - 2017
American Academy of Pain Medicine (AAPM) Annual Meeting	2012 - 2017
American Pain Society: Annual Meeting	2012 - 2017
American Association of Nurse Practitioners (AAPN)	2012 - 2017
American Society of Regional Anesthesia (ASRA) and Pain Medicine: Annual Meeting	2012 - 2017
American Academy of Addiction Psychiatry (AAAP): Annual Meeting and Scientific Symposium	2012 - 2017
Society of Clinical Psychology	2012 - 2017
Physicians for Responsible Opioid Prescribing	2012 - 2017
National Governors Association Meeting	2012 - 2017
National Rx Drug Abuse and Heroin Summit (Atlanta, GA)	2017
North American Drug Dialogue (Washington, DC)	2017
Fentanyl: The Next Wave of the Opioid Crisis – House Energy and Commerce (Washington, DC)	2017
The President’s Forum: The U.S. Opioid Epidemic – The National Academy of Medicine (Washington, DC)	2017
CADCA’s 28th Annual National Leadership Forum and SAMHSA’s 14th Prevention Day (National Harbor, MD)	2017
HHS Opioid Symposium (Washington, DC)	2017
2017 International Conference on Opioids (Boston, MA)	2017
Combating the Opioid Epidemic: A Conversation with the U.S. Surgeon General – CSIS (Washington, DC)	2017

Appendix D: State and Local Search

The ES Report includes a search for CBPs on state and local county websites utilizing various search terms on Google. The state and local search includes the following steps:

1. Google search strings constructed by combination terms from Columns A, B and C from Table 5
2. Manual review of results (websites) from the top two pages of Google to identify reports or publications potentially relevant to directly addressing research questions
   1. Manual search and review of websites for top 50 counties (per capita opioid prescribing rate [CDC data]) if the county website is not included in (2) above.
3. Search results narrowed according to search limits below
4. Review of full text of identified articles to determine if relevant to directly addressing research questions
5. Search limits:
   1. Publications directly addressing research questions
   2. English language articles only
   3. Review of articles included published works since 2012; however, articles published prior to 2012 were included if considered fundamental to understanding the research questions

Table 5: Search Terms

State or County (Column A)	Pain Management (Column B)	Clinical Best Practice (Column C)
local city county states1 top 50 counties2	opioid prescribing pain management chronic pain acute pain	guidelines reports action plans clinical practice guidelines clinical best practices opioid medication-assisted treatment

Appendix E: Clinical Best Practices Analysis

Tables 1-7: Clinical Best Practice (CBP) Analysis

Categories

	Type of Pain	Patient Population	Physician Audience
Arnsteen 2017	Persistent pain management (3+ months)	Older adults	Nurses and other healthcare providers
Bruce 2017	Chronic pain	HIV patients	Not specified
Colorado 2017	Emergency department pain	All ages, specifically those in the ED	Emergency departments
Cornelius 2017	Acute pain management	Older Adults	Nurses and other healthcare providers
Horgas 2017	Pain management	Older Adults	Healthcare providers
Manchikanti 2017	Chronic Non-Cancer Pain	Patients receiving opioids for medical care and pain management	Physicians prescribing opioids
Munzing 2017	Noncancer pain	Not specified	Physicians prescribing opioids
New Jersey 2017	Policy	Policy	Policy
Oregon 2017	Chronic	Not specified	Clinicians and healthcare organizations
Qaseem 2017	Low back pain (acute, subacute, chronic)	Adults	All clinicians
Tehama 2017	Treating chronic pain (3+ months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care	Patients of the age 18 or older in primary care settings	Clinicians
VA/DOD 2017	Opioid Therapy for Chronic Pain	VA and DoD populations	General clinicians or specialists
Cooney 2017	Acute post-op pain	Post-op	Nursing practice
Chou 2016	Post-op; Management of chronic pain, acute nonsurgical pain, dental pain, trauma pain, and periprocedural (nonsurgical) pain are outside the scope of this guideline.	Post-op	Clinicians who manage postoperative pain.
Deng 2016	Neuropathic pain	Not specified	Not specified
Dowell 2016	Opioids for Chronic Pain (not cancer, palliative, EoL)	Adult (not children)	Primary care physicians
Erie 2016	Acute pain;  not patients with chronic pain, pain associated with active cancer treatment, palliative care, hospice and end-of-life care.	"Adults"	Ambulatory settings; They are not intended to address care in emergency departments, post-operative settings or among pediatric patients.
Paice 2016	Chronic pain	Survivors of adult cancer	Healthcare providers who provide care to cancer survivors
West Virginia 2016	Nociceptive, neuropathic, mixed pain	Not specified	Prescriber and dispensers of opioids
Bhatnagar 2015	Cancer pain	Cancer patients	Oncologists and pain physicians
Kampman 2015	Addiction	OUDs	*broad group of physicians*
Mai 2015	Chronic, acute, and surgical	Injured workers	Physicians who prescribe opioids
Marin 2015	Chronic, non-cancer pain	Not specified	*clinicians*
Monterey 2015	Acute and chronic, non-cancer pain	Not specified	Medical providers
Washington 2015	Acute, subacute, perioperative, and chronic	All ages	Clinicians prescribing opioids for pain
Chou 2014	Chronic pain	All ages	Clinicians who prescribe methadone
Hegmann 2014	Acute, subacute, chronic, and postoperative	Working-age adults	Healthcare providers
North Carolina 2014	Chronic and acute pain	Not specified	Clinicians prescribing opioids for pain
Oklahoma 2013	Chronic and acute	Not specified	All clinicians who prescribe opioids in their practice
ASA 2012	Acute pain in the perioperative setting	Not specified	Clinicians who treat acute pain
Hawaii 2012	Acute or chronic non-cancer pain	Emergency department patients	Emergency physicians
San Diego 2012	Acute and chronic	Not specified	Clinicians who prescribe opioids
New Mexico 2011	Chronic and acute	Not specified	All clinicians who prescribe opioids in their practice
ASA and ASRA 2010	Chronic noncancer pain	Non pediatric patients	Anaesthesiologists and other physicians serving as pain medicine specialists.
Chou 2009	Chronic non-cancer pain
Fine 2009	Opioid therapy for pain	Patients taking opioids for therapy or pain management	Not specified
Utah 2009	Chronic and acute	Not specified	All clinicians who prescribe opioids in their practice
Wheeling-Ohio [N/A]	Acute and emergency pain	Patients with acute or emergency conditions	Emergency department

3.2.2 Medication

	3.2.2.1. Optimizing treatments based on differences within and between classes of opioids (CARA)	3.2.2.2 Opioids with abuse deterrent technology (CARA)	3.2.2.3 Pharmacological alternatives to opioids to reduce opioid monotherapy in appropriate cases (CARA)	3.2.2.4 Medication Assisted Treatment (MAT)	3.2.2.5 Co-prescription of benzodiazepines	3.2.2.6 Naloxone
Arnsteen 2017	Analgesic agents are the cornerstone of actue pain management in older adults. Morphine, Methadone, Levorphanol, Gabapentin and prgabalin, serotonin and norepinephrine, tricyclic antidepressant agents, carbamazepine, muscle relaxants, tizanidine, topical high potency capsaicin, benzodiazepine agents, cannabinoids are all listed as potential pain treatment agents. The analgesics' side effects and further recommendations are also listed on page 26.		Acetaminophen, Oral NSAIDs, Topical NSAIDs, Tricyclic antidepressant agents, anticonvulsant agents have been recommended (e.g. pregabalin, gabapentin).
Bruce 2017	Capsaicin, medical cannabis, alpha lipoic acid, and lamotrigine are  a few recommended pharmacological treatments for chronic neuropathic pain in persons living with human immunodeficiency virus (dosage, duration, and full recommendations are on page 3-4).		nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line agents for the treatment of musculoskeletal pain (strong, high). Remark: Acetaminophen has fewer side effects than NSAIDs. Studies typically used 4 g/day dosing of acetaminophen; lower dosing is recommended for patients with liver disease. Compared to traditional NSAIDs, COX-2 NSAIDs are associated with decreased risk of gastrointestinal side effects but increased cardiovascular risk.
Colorado 2017			The CERTA concept optimizes the following medication classes in place of opioids: Cox-1, 2, 3 inhibitors, NMDA receptor antagonists, sodium channel blockers, nitrous oxide, inflammatory cytokine inhibitors, and GABA agonists/modulators. Specific agents include NSAIDs and acetaminophen, ketamine, lidocaine, nitrous oxide, corticosteroids, benzodiazepines, and gabapentin; see (R12-R13) for a full list of clinical recommendations.	The use of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) protocol and SBIRT-trained health educators in the acute setting is associated with a significant decrease in continued drug abuse and an increase in patient follow up for treatment programs. Every Colorado emergency department should consider implementing such a tool. The use of alpha2-agonists, antihistamines, antiemetics, and NSAIDs should be used to ameliorate withdrawal symptoms. Any patient willing to consider treatment and recovery should be directed to a nearby medication assisted treatment (MAT) program (R27-R28).		The initiation of buprenorphine/naloxone (Suboxone) is among the most effective methods for transitioning patients into treatment and recovery. Emergency departments with a high prevalence of opioid-addicted patients should strongly consider implementing a coordinated program that allows those suffering from opioid withdrawal to be inducted on burprenorphine and expeditiously referred or transferred to a MAT program (R28).
Cornelius 2017			Acetaminophen should be consdiered as preferred nonopioid agent for mild to moderate pain. NSAIDs are also recommended with careful monitoring of side effects.
Horgas 2017			Multiple nonopioid pharmacologic treatments have been recommended, such as acetaminophen or other NSAIDs, as first line pharmacotherapy in chronic pain. Multiple other drugs also have been recommended specifically for neuropathic pain which include anticonvulsants (gabapentin or pregabalin), tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors (SNRIs) (412,511-514). However, NSAIDs have been associated with hepatic, gastrointestinal, renal, and cardiovascular risks (208,211,476,481,483,484,514-517). Consequently, acetaminophen and NSAIDs have been used less frequently in recent months due to multiple warnings from the FDA on acetaminophen toxicity, as well as NSAID toxicity (511,517). Anticonvulsants also have been associated with a significant adverse effect profile. Above all, the perceived benefits of acetaminophen, NSAIDs, and anticonvulsants seem to be insignificant and have been always judged in conjunction with other treatments (518). Even though Dowell et al (42) have recommended these as first line and second line treatments and superior to opioids, the effect size of improvement appears to be small (482). Further, some modalities, such as biopsychosocial rehabilitation, are not widely applied in the United States (519).
Manchikanti 2017		Three types of abuse deterrent formulations (ADFs) have been described with multiple physical barriers. Polyethylene oxide, a physical barrier, prevents accidental crushing or chewing. However, sequestered aversive agents, such as niacin, may precipitate adverse events in patients who chew or crush tablets accidentally without intent of abuse, and even intact tablets may produce adverse events from an aversive component in some fully compliant patients. Use of sequestered opioid antagonists, such as naloxone, may represent a more effective approach to pharmacologically deterring abuse by rendering the opioid ineffective, even though it may precipitate an opioid withdrawal in patients who chew their tablet accidentally. Overall, the effectiveness of aberrant opioid deterrence technology is limited due to well-known disadvantages of long-acting drugs and the small proportion of prescriptions of long-acting opioids, specifically those utilizing abuse deterrent technology. However, recent advances in abuse deterrent technologies for the delivery of opioids may improve the effectiveness of this technology in preventing misuse and abuse (460). Unfortunately, these technologies do not prevent taking additional oral medications which is the most common method of abuse.	Multiple nonopioid pharmacologic treatments have been recommended, such as acetaminophen or other NSAIDs, as first line pharmacotherapy in chronic pain. Multiple other drugs also have been recommended specifically for neuropathic pain which include anticonvulsants (gabapentin or pregabalin), tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors (SNRIs) (412,511-514). However, NSAIDs have been associated with hepatic, gastrointestinal, renal, and cardiovascular risks (208,211,476,481,483,484,514-517). Consequently, acetaminophen and NSAIDs have been used less frequently in recent months due to multiple warnings from the FDA on acetaminophen toxicity, as well as NSAID toxicity (511,517). Anticonvulsants also have been associated with a significant adverse effect profile. Above all, the perceived benefits of acetaminophen, NSAIDs, and anticonvulsants seem to be insignificant and have been always judged in conjunction with other treatments (518). Even though Dowell et al (42) have recommended these as first line and second line treatments and superior to opioids, the effect size of improvement appears to be small (482). Further, some modalities, such as biopsychosocial rehabilitation, are not widely applied in the United States (519).			The evidence suggested that opioid users can and will use naloxone to reverse opioid overdoses when properly trained. Further, appropriate training can be provided successfully through community-based opioid overdose prevention programs.
Munzing 2017			Pharmacologic, including topical medications, nonopioid medications (eg, acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants)		Opioids and benzodiazepines (FDA black box warning). “Trinity” or “Holy Trinity”: Opioid plus benzodiazepine plus carisoprodol
New Jersey 2017				The state should increase access to medication assisted treatment (MAT) of substance use disorder. Specifically, incentives should be offered to entice private physicians to partner with licensed treatment agencies to provide access to Buprenorphine, Vivitrol and Naloxone in combination with counseling or other therapeutic interventions (R27).		All EMT’s should be permitted, although not mandated, to carry and dispense Narcan in 4mg doses. Every person who is administered Naloxone by a first-responder should be transported to a hospital to ensure their health and well-being (R26).
Oregon 2017				Clinicians should offer or arrange evidence-based treatment (usually medicationassisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder (R9).	Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible (R9).	Naloxone is recommended when factors increase the risk of overdose (R8).
Qaseem 2017			or acute: If pharmacologic treatment is desired, clinicians and patients; Should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (R1); Chronic: for non-responders, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy; opioids last option (R3)
Tehama 2017				Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.	Discuss effects that opioids may have on ability to safely operate a vehicle, particularly when opioids are initiated, when dosages are increased, or when other central nervous system depressants, such as benzodiazepines or alcohol, are used concurrently.	Clinicians should consider offering naloxone when prescribing opioids to patients at increased risk of overdose.
VA/DOD 2017			Acute: We recommend alternatives to opioids for mild-to-moderate acute pain (R18) When pharmacologic therapies are used, we recommend non-opioids over opioids (R1)		We recommend against the concurrent use of benzodiazepines and opioids (R5)
Cooney 2017			Clinicians offer multimodal analgesia or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence). Clinicians provide adults and children with acetaminophen and/or nonsteroidal antiinflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications (strong recommendation, high-quality evidence). Clinicians consider use of gabapentin or pregabalin as a component of multimodal multimodal analgesia (strong recommendation, moderate-quality evidence). Clinicians consider IV ketamine as a component of multimodal analgesia in adults (weak recommendation, moderatequality evidence). Clinicians consider IV lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery who do not have contraindications (weak recommendation, moderate-quality evidence). Nonopioids are recommended as components of a multimodal analgesic plan.7 The panel cites evidence that shows that acetaminophen and NSAIDs reduce pain and opioid requirements in postsurgical patients.
Chou 2016			The panel recommends that clinicians provide adults and children with acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications (strong recommendation, high-quality evidence). The panel recommends that clinicians consider giving a preoperative dose of oral celecoxib in adult patients without contraindications (strong recommendation, moderate-quality evidence). The panel recommends that clinicians consider use of gabapentin or pregabalin as a component of multimodal analgesia (strong recommendation, moderate-quality evidence). The panel recommends that clinicians consider i.v. ketamine as a component of multimodal analgesia in adults (weak recommendation, moderatequality evidence). The panel recommends that clinicians consider i.v. lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery who do not have contraindications (weak recommendation, moderate-quality evidence).		The panel recommends that clinicians avoid the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine in the treatment of postoperative pain (strong recommendation, moderate-quality evidence).
Deng 2016			The anticonvulsants pregabalin and gabapentin, low-dose TCAs, SSNRIs duloxetine and venlafaxine, and topical lidocaine showed efficacy for the management of NP and were recommended as first-line and second-line medications, respectively.
Dowell 2016			Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain (R1)	Offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder (R12)	Avoid prescribing opioid pain medication and benzodiazepines concurrently (R11)
Erie 2016					Use caution with prescribing opioids for patients on medications causing central nervous system depression (e.g. benzodiazepines and sedative hypnotics) or patients known to use alcohol. Advise patients to avoid use of alcohol or other sedatives while taking opioids, as combinations can increase the risk of respiratory depression and death.
Paice 2016			Clinicians may prescribe the following systemic nonopioid analgesics and adjuvant analgesics to relieve chronic pain and/or improve function in cancer survivors in whom no contraindications including serious drug–drug interactions exist: • Nonsteroidal anti-inflammatory drugs • Acetaminophen (paracetamol) • Adjuvant analgesics, including selected antidepressants and selected anticonvulsants with evidence of analgesic efficacy (such as the antidepressant duloxetine and the anticonvulsants gabapentin and pregabalin) for neuropathic pain conditions or chronic widespread pain (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate) The panel acknowledges that many other systemic nonopioids, including many other antidepressants and anticonvulsants, drugs in many other classes (such as the so-called muscle relaxants, benzodiazepines such as clonazepam, N-methyl-D-aspartate receptor blockers such as ketamine, and a-2 agonists such as tizanidine), and varied neutraceutical and botanicals marketed as complementary or alternative medicines, are taken by some cancer survivors with chronic pain and may benefit some of those who receive them. However, the efficacy of these agents and their longterm effectiveness have not been established. Clinicians may prescribe topical analgesics (such as commercially available nonsteroidal antiinflammatory drugs; local anesthetics; or compounded creams/gels containing baclofen, amitriptyline, and ketamine), for the management of chronic pain. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate) Corticosteroids are not recommended for long-term use in cancer survivors solely to relieve chronic pain. (Evidence-based; harms outweigh benefits; evidence quality: intermediate; strength of recommendation: moderate)		Clinicians should incorporate a universal precautions approach to minimize abuse, addiction, and adverse consequences of opioid use such as opioid-related deaths. Clinicians should be cautious in coprescribing other centrally acting drugs, particularly benzodiazepines (Table 7). (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)
West Virginia 2016					Avoidance of combinations of opioids, benzodiazepines, muscle relaxers, and/or hypnotics due to severity of drug-drug interactions and increased chance for side effects (R22).	Before starting and periodically during continuation ofopioid therapy, clinicians should evaluate risk factors foropioid-relatedharms.Cliniciansshouldincorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, historyof substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present (R24*).
Bhatnagar 2015			Epidural analgesia can provide satisfactory pain relief in intractable cancer pain with efficacy varying from 76–100%. Intrathecal infusion of drugs can be accomplished either by externalized intrathecal catheters or implantable drug delivery systems (IDDS).[8] The safety and efficacy of externalized intrathecal catheters in advanced cancer pain has been demonstrated even for periods extending up to 1.5 years.[89,90] Intrathecal morphine is more effective, has less adverse effects, requires more compact and portable infusion system with longer period to refill as compared to epidural infusion systems.[8,91,92] Home-based intrathecal infusion is cheaper, associated with improved analgesia and QoL
Kampman 2015			If pharmacological treatment is considered, non-narcotic medications such as acetaminophen and NSAIDs should be tried first. Opioid agonists (methadone or buprenorphine) should be considered for patients with active opioid use disorder who are not under treatment. Pharmacotherapy in conjunction with psychosocial treatment should be considered for patients with pain who have opioid use disorder.	Clinicians should consider the patient’s preferences, past treatment history, and treatment setting when deciding between the use of methadone, buprenorphine, and naltrexone in the treatment of addiction involving opioid use
Mai 2015			Evidence-based guidelines on the management of acute low back pain recommend conservative initial therapies (eg, acetaminophen or nonsteroidal anti-inflammatory drugs [NSAIDs]) rather than opioids in almost all cases		Use is not recommended: Any combination of opioids with benzodiazepines, sedative-hypnotics, or barbiturates. There may be specific indications for such combinations, such as the coexistence of spasticity. In such cases, a pain specialist consultation is strongly recommended. Consider alternatives such as tricyclic antidepressants or antihistamines to manage insomnia.
Marin 2015					Caution should be used in patients taking other centrally acting sedatives, including alcohol, antihistamines and benzodiazepines, as such use with chronic opioid therapy increases the risk of over-sedation and adverse events (R4).	Clinicians should consider prescribing naloxone to the patient and provide instructions in how and when to administer naloxone for family members or friends of patients identified to be at high risk for overdose or aberrant drugrelated behavior (R5).
Monterey 2015
Washington 2015			For most pain conditions, non-opioid analgesics (e.g. acetaminophen and NSAIDs) and adjuvant analgesics (e.g. antidepressants and anticonvulsants) are equally or more effective with less risk for harm than opioids (R18).	According to the broad definition in DSM 5, only two criteria must be met to make a diagnosis of a mild disorder. Two of these criteria, tolerance and withdrawal, are normal physiological consequences of COAT. However, these two criteria do not count toward the DSM 5 diagnosis of opioid use disorder if the medication is taken appropriately under ongoing medical treatment. The remaining DSM 5 criteria for opioid use disorder pertain to maladaptive behavior patterns (R40).
Chou 2014				This article is about MAT with methadone.
Hegmann 2014	Conversion of opioids to an MED is helpful to transfer from one opioid to another. This is most commonly performed to attempt to achieve a better functional outcome and/or to reduce adverse effects. Quality evidence to support this practice has not been published.		Among trials for treatment of acute pain, ibuprofen was reportedly superior to codeine or acetaminophen for acute injuries including fractures.85 Diflunisal was equivalent to codeine for sprains, strains, andmild to moderate LBP.86 Valdecoxib* was better tolerated and trended toward greater pain relief than tramadol for ankle sprains.87 Valdecoxib was equivalent to oxycodone as assessed by pain ratings, but trended toward less rescue medication use and had fewer adverse effects among patientswith spine and extremity pain.88 Global ratings for LBP showed that carisoprodol was superior to propoxyphene and has fewer adverse effects.89 Ketorolac was equivalent for pain relief, but superior to meperidine regarding adverse effects for treating severe LBP.90 Ketorolac was also superior to codeine/acetaminophen for acute LBP treated in emergency departments.91 Diflunisal was superior to codeine/APAP for LBP. Routine use of opioids for treatment of acute pain is strongly not recommended and the recommendation for select use of opioids based purely on the evidence is downgraded from “A” to “C”
North Carolina 2014		Patients who have an active substance use disorder should not receive opioid therapy until they are established in a treatment/recovery program (54), or alternatives such as co-management with an addiction professional are established (R7).	First line pharmaco-therapy should be the appropriate use of non-opioid analgesics including over the counter medications, non-steroidal anti-inflammatory drugs, and acetaminophen (R9)		The physician should be continuously attentive to the use of opiates with other respiratory depressants such as benzodiazepines or alcohol, and using opiates in the setting of other comorbidities such as mental illness, respiratory disorders and sleep apnea, and a pre-existing substance use disorder (R12).	The Board expects physicians who prescribe opiates to help insure that naloxone is readily available to patients who are identified as being at risk of an opiate overdose (R11).
Oklahoma 2013			Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) (R7). Opioid medications are usually not the most appropriate first line of treatment for patients with chronic pain. Other measures, such as non-opioid pain medications, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., therapeutic exercise, physical therapy), should be tried first and the outcomes of those therapies documented			Consider co-prescribing naloxone for high risk patients, and providing training to family/caregivers to reverse potential life-threatening depression of the respiratory and central nervous system (R9).
ASA 2012
Hawaii 2012			Opioid analgesics should not necessarily be considered the primary approach to pain management. With consideration to their inherent risks, alternative and effective pharmacological interventions for acute pain include non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, and nerve blocks (e.g. for dental pain).
San Diego 2012
New Mexico 2011		The prescription for opioid therapy should be written on tamper-resistant prescription paper in a manner to help reduce the likelihood of prescription fraud or misuse.		When opioids are to be used for treatment of chronic pain, a written treatment plan should be established that includes measurable goals for reduction of pain and improvement of function. Goals for treatment of chronic pain should be measurable and should include improved function and quality of life as well as improved control of pain. They should be developed jointly between the patient and physician. Continuation or modification of therapy should depend on the clinician’s evaluation of progress towards stated treatment goals (R27).
ASA and ASRA 2010			Multimodal interventions should be part of a treatment strategy for patients with chronic pain. Single modality interventions, as components of a multimodality approach to pain management, include, but are not limited to, the following: (1) ablative techniques, (2) acupuncture, (3) blocks (i.e., joint and nerve or nerve root), (4) botulinum toxin injections, (5) electrical nerve stimulation, (6) epidural steroids with or without local anesthetics, (7) intrathecal drug therapies, (8) minimally invasive spinal procedures, (9) pharmacologic management, (10) physical or restorative therapy, (11) psychologic treatment, and (12) trigger point injections.
Chou 2009
Fine 2009
Utah 2009
Wheeling-Ohio [N/A]					Whenever possible, do not prescribe opioid analgesics to a patient currently taking benzodiazepines and/or other opioid drugs or medications. Emergency department personnel should not prescribe opioid analgesics to a patient currently taking benzodiazepines and/or other opioid drugs or medications unless the opioid analgesic prescription is medically necessary to treat the patient’s reported pain. If an opioid analgesic is prescribed in combination with benzodiazepines and/or other opioid drugs, the patient should be advised to consult closely with their primary care physician or a pain management specialist.

3.2.3 Physical Therapy

	3.2.3.1 Traditional Physical Therapy	3.2.3.2 Functional restoration
Arnsteen 2017	Therapeutic exercises, salves, supplements, and self-management techniques are commonly used and aid in reducing medication-related side effects. Yoga may reverse pain and age-related loss of gray matter. Moderate pressure massage and Iyengar yoga may be best to reduce pain while improving balance and mobility
Bruce 2017	Yoga is recommended for the treatment of chronic neck/ back pain, headache, rheumatoid arthritis, and general musculoskeletal pain (strong, moderate). Physical and occupational therapy are recommended for chronic pain (strong, low).
Colorado 2017		Alternative treatments, including early mobilization and physical therapy, can improve return to function and decrease disability and should be used as first-line agents in the treatment of this complaint.
Cornelius 2017
Horgas 2017	There is a wide range of nonpharmacologic strategies aimed at physical activity (eg, exercise, activity modification), nutrition (eg, vitamins and supplements), external applications (eg, ointments, massage, heat/cold application), and relaxation/ distraction (eg, breathing, meditation, imagery, music)
Manchikanti 2017	Exercise therapy has been recommended to reduce pain and improve function in chronic pain (208,211,461-465). However, exercise therapy alone may not provide a meaningful response for any condition. Consequently, multimodal and multidisciplinary therapies may help to reduce pain and improve function more effectively than single modalities	Exercise therapy has been recommended to reduce pain and improve function in chronic pain (208,211,461-465). However, exercise therapy alone may not provide a meaningful response for any condition. Consequently, multimodal and multidisciplinary therapies may help to reduce pain and improve function more effectively than single modalities
Munzing 2017
New Jersey 2017
Oregon 2017
Qaseem 2017
Tehama 2017
VA/DOD 2017	Exercies (PT) preferred over long-term opioid therapy. Physical interventions (e.g., physical therapy, active/passive exercise, ultrasound stimulation, chiropractic, osteopathic manipulation therapy). Discussion of an individualized comprehensive care plan that may include, in additionto OT, physical therapy, occupational therapy, cognitive-behavioral therapy, acupuncture, manipulation, complementary and alternative medicine, other non-pharmacologic therapies, and other non-opioid agents
Cooney 2017
Chou 2016
Deng 2016
Dowell 2016	The contextual evidence review found that many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain. Although there are perceptions that opioid therapy for chronic pain is less expensive than more timeintensive nonpharmacologic management approaches, many pain treatments, including acetaminophen, NSAIDs, tricyclic antidepressants, and massage therapy, are associated with lower mean and median annual costs compared with opioid therapy (174). COX-2 inhibitors, SNRIs, anticonvulsants, topical analgesics, physical therapy, and CBT are also associated with lower median annual costs compared with opioid therapy (174).	Experts thought that goals should include improvement in both pain relief and function (and therefore in quality of life). However, there are some clinical circumstances under which reductions in pain without improvement in physical function might be a more realistic goal (e.g., diseases typically associated with progressive functional impairment or catastrophic injuries such as spinal cord trauma).
Erie 2016	Non-Pharmacologic Treatment should be considered as first-line therapy for acute pain unless the natural history of the cause of pain or clinical judgement warrants a different approach. These therapies often reduce pain with fewer side effects and can be used in combination with non-opioid medications to increase likelihood of success. Examples may include, but are not limited to: Ice, heat, positioning, bracing, wrapping, splints, stretching and directed exercise often available through physical therapy
Paice 2016	Physical therapy, occupational therapy, recreational therapy, individualized exercise program, orthotics, ultrasound, heat/cold (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate); discusses functional impairment and outcomes in the context of screening and whether to px opiods	Physical therapy, occupational therapy, recreational therapy, individualized exercise program, orthotics, ultrasound, heat/cold (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate); discusses functional impairment and outcomes in the context of screening and whether to px opiods
West Virginia 2016
Bhatnagar 2015
Kampman 2015
Mai 2015	Nonpharmacologic treatments, such as cognitive-behavioral therapy, activity coaching, and graded exercise, are also encouraged.	Beyond the acute phase, effective use of opioids should result in clinically meaningful improvement in function (CMIF). Providers should track function and pain on a regular basis, using the same validated instruments at each visit, to consistently determine the effect of opioid therapy.
Marin 2015
Monterey 2015
Washington 2015	Yoga, relaxation, activity coaching, graded exercise. Pain is a multidimensional experience; so therefore, pain management is most effective when a multimodal approach is utilized (Table 1). In addition to medication, therapies should include physical activation and behavioral health interventions (such as cognitive behavioral therapy, mindfulness, coaching, patient education, and self-management).
Chou 2014
Hegmann 2014
North Carolina 2014	Early treatment with non-pharmacologic interventions including physical therapy, exercise, and cognitive behavioral techniques, should be employed whenever possible. First line pharmaco-therapy should be the appropriate use of non-opioid analgesics including over the counter medications, non-steroidal anti-inflammatory drugs, and acetaminophen. Other treatment modalities including minor interventions such as anesthetic and steroid joint injections, cutaneous stimulators, topical anesthetics, and local therapies employing heat, massage, and manipulations should be considered before using opiates.	All physicians should be knowledgeable about the process of evaluating their patients’ pain and function, and be familiar with methods of managing pain safely and effectively. The process of evaluation and management of a patient’s pain should be based on an established physician-patient relationship. Patients with chronic pain should be assessed for the potential for substance abuse and coexistent mental health conditions. Objective and verifiable goals that incorporate physical, functional and social domains should be prominent components of a patient’s treatment plan.
Oklahoma 2013	Therapeutic exercise, physical therapy (R5). Opioid medications are usually not the most appropriate first line of treatment for patients with chronic pain. Other measures, such as non-opioid pain medications, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., therapeutic exercise, physical therapy), should be tried first and the outcomes of those therapies documented
ASA 2012
Hawaii 2012
San Diego 2012
New Mexico 2011	Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first.
ASA and ASRA 2010	Consultants, ASA members, and ASRA members strongly agree that physical or restorative therapy should be used for patients with low back pain. Similarly, they strongly agree that physical or restorative therapy should be used for other (nonlow back pain) chronic pain conditions.
Chou 2009
Fine 2009
Utah 2009
Wheeling-Ohio [N/A]

3.2.4 Psychological

	3.2.4.1 Traditional Psychological Interventions	3.2.4.2 Self-management	3.2.5 Surgical and Minimally Invasive Procedures	3.2.5.1 Ultrasound guided blocks for acute pain	3.2.5.2 Neuromodulation	3.2.6 Complementary and Alternative Medicine (CARA)	3.2.6.1 Acupuncture
Arnsteen 2017	Older adults have better outcomes 6 months after completeting acceptance and commitment therapy than cognitive-behavioral therapy; hypnosis is found to be helpful in hospitalized older patients					Physical and cognititve behavioral; therapeutic exercises, salves, supplements, and self-management techniques, mind-body therapies	Auricular point acupressure provides significant prain relief to some older adults with low back pain
Bruce 2017	Cognitive behavioral therapy (CBT) is recommended for chronic pain management (strong, moderate). Remark: CBT promotes patient acceptance of responsibility for change and the development of adaptive behaviors (eg, exercise) while addressing maladaptive behaviors (eg, avoiding exercise due to fears of pain). Hypnosis is recommended for neuropathic pain (strong, low).						Clinicians might consider a trial of acupuncture for chronic pain (weak, moderate). Values and preferences: This recommendation places a relatively high value on the reduction of symptoms and few undesirable effects. Remark: Evidence to date is available only for acupuncture in the absence of amitriptyline and among PLWH with poorer health in the era before highly active antiretroviral therapy.
Colorado 2017		Cognitive behavioral therapy (CBT) is recommended for chronic pain management (strong, moderate). Remark: CBT promotes patient acceptance of responsibility for change and the development of adaptive behaviors (eg, exercise) while addressing maladaptive behaviors (eg, avoiding exercise due to fears of pain). (Self-management is CBT-based)				Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed. Alternative treatments, including early mobilization and physical therapy, can improve return to function and decrease disability and should be used as first-line agents in the treatment of this complaint (R7). See (R12) for a full list of clinical recommendations.
Cornelius 2017	CBTs that promote relaxation provide a moderate to large beneficial effect on pain. Simple relaxation, guided imagery, distraction techniques, video or TV, singing, praying, positive-self talk, or tapping a rhythm.					Implementing basic comfort, consider music, imagery, distractions, altering the environment to provide comfort (lighting, noise, privacy, position changes). Some older adults may use prayer and meditation.	Acupuncture, massage, or cold application as adjuncts to postoperative pain relief has limited evidence to recommend or discourage use for adults.
Horgas 2017	There is evidence to support the use of acupuncture, mindfulness meditation, massage, TENS, and cognitive behavioral therapy to treat pain.	It should be emphasized that pharmaceutical pain management is often more imperative in older adults with dementia because their ability to participate in nonpharmacologic pain management strategies, such as self-management or cognitive behavioral therapy, may be limited by their cognitive capacity.			Transcutaneous electrical nerve stimulation (TENS) is also commonly used and is now commercially available as an OTC medical device. Because pain is multidimensional with physical, psychological, and emotional aspects, the inclusion of psychosocial interventions is recommended	Older adult patients should be prescribed nonpharmacologic treatment, separately or in combination with drug therapy, to achieve effective pain management	There is evidence to support the use of acupuncture, mindfulness meditation, massage, TENS, and cognitive behavioral therapy to treat pain.
Manchikanti 2017	Dowell et al (42) described cognitive behavior therapy (CBT) as having small positive effects on disability and catastrophic thinking (476). Despite the major recommendation by Dowell et al (42), a Cochrane systematic review of multidisciplinary biopsychosocial rehabilitation for chronic low back pain by Kamper et al (482) concluded that with less pain and disability obtained with biopsychosocial rehabilitation compared to those receiving usual care or a physical treatment, the effects were of modest magnitude and should be balanced against the time and resource requirements of multidisciplinary rehabilitation programs. They also showed that more intensive interventions were not responsible for effects that were substantially different from less intensive interventions. Further, they also felt that only those people with indicators of significant psychosocial impact may be referred to multidisciplinary biopsychosocial rehabilitation.				Multiple systematic reviews have assessed the clinical and cost effectiveness of spinal cord stimulation in managing chronic spinal pain. Page S44.
Munzing 2017	Depending on the pain severity, treatment must be tailored using multiple tools. Such tools include 1) nonpharmacologic (eg, physical therapy, heat, ice, massage, rest, exercise, meditation, cognitive-behavioral therapy, treating comorbid conditions)			Depending on the pain severity, treatment must be tailored using multiple tools. Procedures (eg, joint and trigger point injections, nerve blocks, epidural injections)	Depending on the pain severity, treatment must be tailored using multiple tools. For examples: 5) devices (eg, transcutaneous electrical nerve stimulation, implanted neurostimulators).	Nonpharmacologic (eg, physical therapy, heat, ice, massage, rest, exercise, meditation, cognitive-behavioral therapy, treating comorbid conditions); devices (eg, transcutaneous electrical nerve stimulation, implanted neurostimulators)
New Jersey 2017						Hospitals across the state should be encouraged to look at the success of the ALTO project at St. Joseph’s Hospital in Paterson and either adopt it, or take a hard look at alternatives to pain management in their facilities and adopt methods that will lead to a dramatic lessening of opioid prescribing/dispensing (R25).
Oregon 2017						Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate (R6).
Qaseem 2017						Acute, Subacute: clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation (R1); Chronic: should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (R2).  Chronic: for non-responders, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy; opioids last option (R3).
Tehama 2017	Non-pharmacologic therapy (such as Cognitive Behaviorial Therapy (CBT) and exercise) should be used to reduce pain and improve function in patients with chronic pain. Aspects of these approaches can be used even when there is limited access to specialty care. For example, primary care clinicians can encourage patients to take an active role in the care plan and support patients in engaging in exercise. Experts noted that function can include emotional and social as well as physical dimensions. In addition, experts emphasized that mood has important interactions with pain and function. Clinicians may use validated instruments such as the 3-item “Pain average, interference with Enjoyment of life, and interference with General activity” (PEG) Assessment Scale to track patient outcomes (See Appendix A). Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function. Because depression, anxiety, and other psychological comorbidities often coexist with and can interfere with resolution of pain, clinicians should use validated instruments to assess for these conditions and ensure that treatment for these conditions is optimized.					Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. Non-opioid pharmacologic therapy (such as nonsteroidal anti-inflammatories (NSAIDs), acetaminophen, anticonvulsants, and serotonin and norepinephrine reuptake inhibitors (SNRIs)) should be used when benefits outweigh risks and should be combined with non-pharmacologic therapy
VA/DOD 2017		We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments.				Recommend non-pharm over pharm (R1); Recommend against long-term opioid therapy for chronic pain (R1); for pharm, recommend non-opioid (R1)
Cooney 2017	Clinicians consider the use of cognitive behavioral modalities in adults as part of a multimodal approach (weak recommendation, moderate-quality evidence). As components of a multimodal plan, cognitive behavioral therapies such as hypnosis, guided imagery, music, and relaxation methods have shown some positive effects on postoperative pain, anxiety, or analgesic use, but few studies of these modalities have been conducted with children			Clinicians use topical local anesthetics in combination with nerve blocks before circumcision (strong recommendation, moderate-quality evidence).	Clinicians consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments (weak recommendation, moderate-quality evidence).		either recommends nor discourages acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence). There is insufficient evidence to recommend the use of acupuncture
Chou 2016	The panel recommends that clinicians consider the use of cognitive–behavioral modalities in adults as part of a multimodal approach (weak recommendation, moderate-quality evidence).			The panel recommends that clinicians use topical local anesthetics in combination with nerve blocks before circumcision (strong recommendation, moderate-quality evidence). The panel recommends that clinicians consider the addition of clonidine as an adjuvant for prolongation of analgesia with a single-injection peripheral neural blockade (weak recommendation, moderate-quality evidence).	The panel recommends that clinicians consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments (weak recommendation, moderate-quality evidence).	The panel recommends that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence).	The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence).
Deng 2016
Dowell 2016						Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain (R1)
Erie 2016						Non-Pharmacologic Treatment should be considered as first-line therapy for acute pain unless the natural history of the cause of pain or clinical judgement warrants a different approach. These therapies often reduce pain with fewer side effects and can be used in combination with non-opioid medications to increase likelihood of success.                              1) Somatic Pain • Acetaminophen • Non-steroidal anti-inflammatory drugs (NSAIDS) • Corticosteroids • Alternatives include: Gabapentin/Pregabalin, skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors and tricyclic antidepressants. 2) Visceral Pain • Acetaminophen • NSAIDS • Corticosteroids           • Alternatives include the following: Dicyclomine, serotonin-norepinephrine reuptake inhibitors, topical anesthetics and tricyclic antidepressants.                                                                        3) Neuropathic Pain • Gabapentin/Pregabalin • Serotonin and norepinephrine reuptake inhibitors • Tricyclic antidepressants • Alternatives include: other antiepileptics, Baclofen, Bupropion, low-concentration Capsaicin, selective serotonin reuptake inhibitors and topical Lidocaine	Non-Pharmacologic Treatment should be considered as first-line therapy for acute pain unless the natural history of the cause of pain or clinical judgement warrants a different approach. These therapies often reduce pain with fewer side effects and can be used in combination with non-opioid medications to increase likelihood of success. Examples may include, but are not limited to: Massage therapy, tactile stimulation, acupuncture/acupressure, chiropractic adjustment, manipulation, and osteopathic neuromuscular care
Paice 2016	Cognitive behavioral therapy, distraction, mindfulness, relaxation, guided imagery (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)			Nerve blocks, neuraxial infusion (epidural/intrathecal), vertebroplasty/kyphoplasty (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)	TENS, spinal cord stimulation, peripheral nerve stimulation, transcranial stimulation (Evidence-based; benefits outweigh harms; evidence quality: low; strength of recommendation: weak)		Massage, acupuncture, music (Evidence-based; benefits outweigh harms; evidence quality: low; strength of recommendation: weak)
West Virginia 2016						Recommended before opioid usage (R15).
Bhatnagar 2015				Neurolytic celiac plexus block. NCPB is the most common cancer pain intervention performed and is highly effective for upper abdominal visceral pain. CPB appears to be safe and effective for pain relief in patients with pancreatic cancer, with significant advantage over standard analgesic therapy [II B].[39] The quality of evidence according to scoring system published by Guyatt et al., is 2 A+ (highest level of evidence, positive recommendation). The level of evidence for endoscopic ultrasound (EUS) celiac plexus neurolysis is B (single RCT/nonrandomized studies) with IIA recommendation (useful).[41] The level of evidence and recommendation for neurolytic SNB is 2 B+ (RCTs with methodological weakness, positive recommendation). The interventional treatment may be considered as soon as opioids are started Splanchnic nerve block, neurolytic superior hypogastric plexus block	Neurolytic celiac plexus block. NCPB is the most common cancer pain intervention performed and is highly effective for upper abdominal visceral pain. CPB appears to be safe and effective for pain relief in patients with pancreatic cancer, with significant advantage over standard analgesic therapy [II B].[39] The quality of evidence according to scoring system published by Guyatt et al., is 2 A+ (highest level of evidence, positive recommendation). The level of evidence for endoscopic ultrasound (EUS) celiac plexus neurolysis is B (single RCT/nonrandomized studies) with IIA recommendation (useful).[41] The level of evidence and recommendation for neurolytic SNB is 2 B+ (RCTs with methodological weakness, positive recommendation). The interventional treatment may be considered as soon as opioids are started Splanchnic nerve block, neurolytic superior hypogastric plexus block	Neurolytic celiac plexus block, Splanchnic nerve block, neurolytic superior hypogastric plexus block, vertebroplasty, kyphoplasty. See above for scoring and recommendations
Kampman 2015
Mai 2015	Adjuvant agents like clonidine and psychological support such as cognitive behavioral therapy can be provided to assist with the taper process. The AP may also seek consultative assistance from a pain management specialist. Nonpharmacologic treatments, such as cognitive-behavioral therapy, activity coaching, and graded exercise, are also encouraged.					Nonpharmacologic treatments, such as cognitive-behavioral therapy, activity coaching, and graded exercise, are also encouraged
Marin 2015
Monterey 2015
Washington 2015	CBTs, mindfulness, meditation. Pain is a multidimensional experience; so therefore, pain management is most effective when a multimodal approach is utilized (Table 1). In addition to medication, therapies should include physical activation and behavioral health interventions (such as cognitive behavioral therapy, mindfulness, coaching, patient education, and self-management).	In addition to medication, therapies should include physical activation and behavioral health interventions (such as cognitive behavioral therapy, mindfulness, coaching, patient education, and self-management).				CBTs, mindfulness, meditation, yoga, relaxation, biofeedback, activity coaching, graded exercise, Identify existential distress, seek meaning and purpose in life, promote patient efforts aimed at increased functional capabilities (R14). Pain is a multidimensional experience; so therefore, pain management is most effective when a multimodal approach is utilized (Table 1). In addition to medication, therapies should include physical activation and behavioral health interventions (such as cognitive behavioral therapy, mindfulness, coaching, patient education, and self-management).
Chou 2014
Hegmann 2014					One trial suggests that transcutaneous electrical stimulationwas equivalent to codeine/acetaminophen for acute trauma
North Carolina 2014	This technique uses the imaginative capacity of one’s own mind to create a relaxed state or, alternatively, to overcome some troubling aspect of life. This method of therapy has been used with success as one treatment for chronic pain (213).					Early treatment with non-pharmacologic interventions including physical therapy, exercise, and cognitive behavioral techniques, should be employed whenever possible. Other treatment modalities including minor interventions such as anesthetic and steroid joint injections, cutaneous stimulators, topical anesthetics, and local therapies employing heat, massage, and manipulations should be considered before using opiates (R9).	An ancient oriental medical technique where needles are placed at anatomic points along the 12 meridians of the body. Oriental medical theory, passed down for thousands of years, states that vital energy (chi) flows through the body along these 12 meridians. Although current medicine does not fully understand how acupuncture works, we do know from functional MRI studies that acupuncture activates/deactivates particular areas of the brain during needling. In addition, it is known that endorphin (endogenous opioid) levels rise during needling. Clinically, acupuncture has been successfully employed to treat a variety of disorders including opioid addiction (198).
Oklahoma 2013
ASA 2012				Regional blockade with local anesthetics should be considered.		Whenever possible, anesthesiologists should use multimodal pain management therapy: NSAIDs, COXIBs, or acetaminophen calcium channel antagonists
Hawaii 2012				Mentioned - Opioid analgesics should not necessarily be considered the primary approach to pain management. With consideration to their inherent risks, alternative and effective pharmacological interventions for acute pain include non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, and nerve blocks (e.g. for dental pain).		With consideration to their inherent risks, alternative and effective pharmacological interventions for acute pain include non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, and nerve blocks (e.g. for dental pain). Non-pharmacological therapies, such as fracture immobilization and proper elevation of injured extremities, may obviate the need for additional pain medications. Short-acting opioid analgesics such as hydrocodone, immediaterelease oxycodone, and hydromorphone may be considered as adjuncts to relieve acute pain when the severity of the pain warrants their use or when non-opioid medications have not provided adequate relief from pain (R2).
San Diego 2012
New Mexico 2011	Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first.					Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise, physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies have proven inadequate (R13-14).	Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first.
ASA and ASRA 2010	Cognitive behavioral therapy, biofeedback, or relaxation training: These interventions may be used as part of a multimodal strategy for low back pain and for other chronic pain conditions. Supportive psychotherapy, group therapy, or counseling: These interventions may be considered as part of a multimodal strategy for chronic pain management.			Guidelines focus specifically on interventional diagnostic procedures including, but not limited to, diagnostic joint block (i.e., facet and sacroiliac), diagnostic nerve block (e.g., peripheral or sympathetic, celiac plexus and hypogastric), provocative discography, or neuraxial opioid trials. Celiac plexus blocks using local anesthetics with or without steroids may be used for the treatment of pain secondary to chronic pancreatitis. Lumbar sympathetic blocks or stellate ganglion blocks may be used as components of the multimodal treatment of CRPS if used in the presence of consistent improvement and increasing duration of pain relief. Sympathetic nerve blocks should not be used for long-term treatment of non-CRPS neuropathic pain. Medial branch blocks may be used for the treatment of facet-mediated spine pain. Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.	Subcutaneous peripheral nerve stimulation: Subcutaneous peripheral nerve stimulation may be used in the multimodal treatment of patients with painful peripheral nerve injuries who have not responded to other therapies. Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies. It may also be considered for other selected patients (e.g., those with CRPS, peripheral neuropathic pain, peripheral vascular disease, or postherpetic neuralgia). Shared decision making regarding spinal cord stimulation should include a specific discussion of potential complications associated with spinal cord stimulator placement. A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device. TENS: TENS should be used as part of a multimodal approach to pain management for patients with chronic back pain and may be used for other pain conditions (e.g., neck and phantom limb pain).	These Guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of chronic pain and pain-related problems. The Guidelines recognize that the management of chronic pain occurs within the broader context of health care, including psychosocial function and quality of life. The article recommends 11 opioid alternatives.	Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, noninflammatory low back pain.
Chou 2009	Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, noninflammatory low back pain.
Fine 2009
Utah 2009						Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., physical therapy), should be tried and the outcomes of those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies have proven inadequate (R16).
Wheeling-Ohio [N/A]						Opioid analgesic medications should not be the preliminary or primary course of treatment designed to relieve a patient’s reported pain. Whenever possible, emergency department staff should consider the use of non-opioid medications and other alternative pain-relief treatments before opioid analgesic medications are prescribed to treat a patient’s reported pain. Whenever possible and appropriate, emergency department personnel should recommend non-opioid medication such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and nerve blocks to treat a patient’s reported pain. Whenever possible and appropriate, emergency department personnel should also consider the use of other therapies and treatments that do not require medication to treat a patient’s reported pain. Opioid analgesic medications should only be prescribed after these alternative treatment options have been thoroughly considered and when the emergency department personnel has determined that an opioid analgesic medication is medically necessary to treat a patient’s reported pain.

3.2.5 Surgical and Minimally Invasive Procedure

	3.2.5.1 Ultrasound guided blocks for acute pain	3.2.5.2 Neuromodulation	3.2.6 Complementary and Alternative Medicine (CARA)	3.2.6.1 Acupuncture
Arnsteen 2017			Physical and cognititve behavioral; therapeutic exercises, salves, supplements, and self-management techniques, mind-body therapies	Auricular point acupressure provides significant prain relief to some older adults with low back pain
Bruce 2017				Clinicians might consider a trial of acupuncture for chronic pain (weak, moderate). Values and preferences: This recommendation places a relatively high value on the reduction of symptoms and few undesirable effects. Remark: Evidence to date is available only for acupuncture in the absence of amitriptyline and among PLWH with poorer health in the era before highly active antiretroviral therapy.
Colorado 2017			Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed. Alternative treatments, including early mobilization and physical therapy, can improve return to function and decrease disability and should be used as first-line agents in the treatment of this complaint (R7). See (R12) for a full list of clinical recommendations.
Cornelius 2017			Implementing basic comfort, consider music, imagery, distractions, altering the environment to provide comfort (lighting, noise, privacy, position changes). Some older adults may use prayer and meditation.	Acupuncture, massage, or cold application as adjuncts to postoperative pain relief has limited evidence to recommend or discourage use for adults.
Horgas 2017		Transcutaneous electrical nerve stimulation (TENS) is also commonly used and is now commercially available as an OTC medical device. Because pain is multidimensional with physical, psychological, and emotional aspects, the inclusion of psychosocial interventions is recommended	Older adult patients should be prescribed nonpharmacologic treatment, separately or in combination with drug therapy, to achieve effective pain management	There is evidence to support the use of acupuncture, mindfulness meditation, massage, TENS, and cognitive behavioral therapy to treat pain.
Manchikanti 2017		Multiple systematic reviews have assessed the clinical and cost effectiveness of spinal cord stimulation in managing chronic spinal pain. Page S44.
Munzing 2017	Depending on the pain severity, treatment must be tailored using multiple tools. Procedures (eg, joint and trigger point injections, nerve blocks, epidural injections)	Depending on the pain severity, treatment must be tailored using multiple tools. For examples: 5) devices (eg, transcutaneous electrical nerve stimulation, implanted neurostimulators).	Nonpharmacologic (eg, physical therapy, heat, ice, massage, rest, exercise, meditation, cognitive-behavioral therapy, treating comorbid conditions); devices (eg, transcutaneous electrical nerve stimulation, implanted neurostimulators)
New Jersey 2017			Hospitals across the state should be encouraged to look at the success of the ALTO project at St. Joseph’s Hospital in Paterson and either adopt it, or take a hard look at alternatives to pain management in their facilities and adopt methods that will lead to a dramatic lessening of opioid prescribing/dispensing (R25).
Oregon 2017			Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate (R6).
Qaseem 2017			Acute, Subacute: clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation (R1); Chronic: should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (R2).  Chronic: for non-responders, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy; opioids last option (R3).
Tehama 2017			Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. Non-opioid pharmacologic therapy (such as nonsteroidal anti-inflammatories (NSAIDs), acetaminophen, anticonvulsants, and serotonin and norepinephrine reuptake inhibitors (SNRIs)) should be used when benefits outweigh risks and should be combined with non-pharmacologic therapy
VA/DOD 2017			Recommend non-pharm over pharm (R1); Recommend against long-term opioid therapy for chronic pain (R1); for pharm, recommend non-opioid (R1)
Cooney 2017	Clinicians use topical local anesthetics in combination with nerve blocks before circumcision (strong recommendation, moderate-quality evidence).	Clinicians consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments (weak recommendation, moderate-quality evidence).		Neither recommends nor discourages acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence). There is insufficient evidence to recommend the use of acupuncture
Chou 2016	The panel recommends that clinicians use topical local anesthetics in combination with nerve blocks before circumcision (strong recommendation, moderate-quality evidence). The panel recommends that clinicians consider the addition of clonidine as an adjuvant for prolongation of analgesia with a single-injection peripheral neural blockade (weak recommendation, moderate-quality evidence).	The panel recommends that clinicians consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments (weak recommendation, moderate-quality evidence).	The panel recommends that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence).	The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence).
Deng 2016
Dowell 2016			Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain (R1)
Erie 2016			Non-Pharmacologic Treatment should be considered as first-line therapy for acute pain unless the natural history of the cause of pain or clinical judgement warrants a different approach. These therapies often reduce pain with fewer side effects and can be used in combination with non-opioid medications to increase likelihood of success.                              1) Somatic Pain • Acetaminophen • Non-steroidal anti-inflammatory drugs (NSAIDS) • Corticosteroids • Alternatives include: Gabapentin/Pregabalin, skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors and tricyclic antidepressants. 2) Visceral Pain • Acetaminophen • NSAIDS • Corticosteroids                                       • Alternatives include the following: Dicyclomine, serotonin-norepinephrine reuptake inhibitors, topical anesthetics and tricyclic antidepressants.                                                                        3) Neuropathic Pain • Gabapentin/Pregabalin • Serotonin and norepinephrine reuptake inhibitors • Tricyclic antidepressants • Alternatives include: other antiepileptics, Baclofen, Bupropion, low-concentration Capsaicin, selective serotonin reuptake inhibitors and topical Lidocaine	Non-Pharmacologic Treatment should be considered as first-line therapy for acute pain unless the natural history of the cause of pain or clinical judgement warrants a different approach. These therapies often reduce pain with fewer side effects and can be used in combination with non-opioid medications to increase likelihood of success. Examples may include, but are not limited to: Massage therapy, tactile stimulation, acupuncture/acupressure, chiropractic adjustment, manipulation, and osteopathic neuromuscular care
Paice 2016	Nerve blocks, neuraxial infusion (epidural/intrathecal), vertebroplasty/kyphoplasty (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)	TENS, spinal cord stimulation, peripheral nerve stimulation, transcranial stimulation (Evidence-based; benefits outweigh harms; evidence quality: low; strength of recommendation: weak)		Massage, acupuncture, music (Evidence-based; benefits outweigh harms; evidence quality: low; strength of recommendation: weak)
West Virginia 2016			Recommended before opioid usage (R15).
Bhatnagar 2015	Neurolytic celiac plexus block. NCPB is the most common cancer pain intervention performed and is highly effective for upper abdominal visceral pain. CPB appears to be safe and effective for pain relief in patients with pancreatic cancer, with significant advantage over standard analgesic therapy [II B].[39] The quality of evidence according to scoring system published by Guyatt et al., is 2 A+ (highest level of evidence, positive recommendation). The level of evidence for endoscopic ultrasound (EUS) celiac plexus neurolysis is B (single RCT/nonrandomized studies) with IIA recommendation (useful).[41] The level of evidence and recommendation for neurolytic SNB is 2 B+ (RCTs with methodological weakness, positive recommendation). The interventional treatment may be considered as soon as opioids are started Splanchnic nerve block, neurolytic superior hypogastric plexus block	Neurolytic celiac plexus block. NCPB is the most common cancer pain intervention performed and is highly effective for upper abdominal visceral pain. CPB appears to be safe and effective for pain relief in patients with pancreatic cancer, with significant advantage over standard analgesic therapy [II B].[39] The quality of evidence according to scoring system published by Guyatt et al., is 2 A+ (highest level of evidence, positive recommendation). The level of evidence for endoscopic ultrasound (EUS) celiac plexus neurolysis is B (single RCT/nonrandomized studies) with IIA recommendation (useful).[41] The level of evidence and recommendation for neurolytic SNB is 2 B+ (RCTs with methodological weakness, positive recommendation). The interventional treatment may be considered as soon as opioids are started Splanchnic nerve block, neurolytic superior hypogastric plexus block	Neurolytic celiac plexus block, Splanchnic nerve block, neurolytic superior hypogastric plexus block, vertebroplasty, kyphoplasty. See above for scoring and recommendations
Kampman 2015
Mai 2015			Nonpharmacologic treatments, such as cognitive-behavioral therapy, activity coaching, and graded exercise, are also encouraged
Marin 2015
Monterey 2015
Washington 2015			CBTs, mindfulness, meditation, yoga, relaxation, biofeedback, activity coaching, graded exercise, Identify existential distress, seek meaning and purpose in life, promote patient efforts aimed at increased functional capabilities (R14). Pain is a multidimensional experience; so therefore, pain management is most effective when a multimodal approach is utilized (Table 1). In addition to medication, therapies should include physical activation and behavioral health interventions (such as cognitive behavioral therapy, mindfulness, coaching, patient education, and self-management).
Chou 2014
Hegmann 2014		One trial suggests that transcutaneous electrical stimulationwas equivalent to codeine/acetaminophen for acute trauma
North Carolina 2014			Early treatment with non-pharmacologic interventions including physical therapy, exercise, and cognitive behavioral techniques, should be employed whenever possible. Other treatment modalities including minor interventions such as anesthetic and steroid joint injections, cutaneous stimulators, topical anesthetics, and local therapies employing heat, massage, and manipulations should be considered before using opiates (R9).	An ancient oriental medical technique where needles are placed at anatomic points along the 12 meridians of the body. Oriental medical theory, passed down for thousands of years, states that vital energy (chi) flows through the body along these 12 meridians. Although current medicine does not fully understand how acupuncture works, we do know from functional MRI studies that acupuncture activates/deactivates particular areas of the brain during needling. In addition, it is known that endorphin (endogenous opioid) levels rise during needling. Clinically, acupuncture has been successfully employed to treat a variety of disorders including opioid addiction (198).
Oklahoma 2013
ASA 2012	Regional blockade with local anesthetics should be considered.		Whenever possible, anesthesiologists should use multimodal pain management therapy: NSAIDs, COXIBs, or acetaminophen calcium channel antagonists
Hawaii 2012	Mentioned - Opioid analgesics should not necessarily be considered the primary approach to pain management. With consideration to their inherent risks, alternative and effective pharmacological interventions for acute pain include non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, and nerve blocks (e.g. for dental pain).		With consideration to their inherent risks, alternative and effective pharmacological interventions for acute pain include non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, and nerve blocks (e.g. for dental pain). Non-pharmacological therapies, such as fracture immobilization and proper elevation of injured extremities, may obviate the need for additional pain medications. Short-acting opioid analgesics such as hydrocodone, immediaterelease oxycodone, and hydromorphone may be considered as adjuncts to relieve acute pain when the severity of the pain warrants their use or when non-opioid medications have not provided adequate relief from pain (R2).
San Diego 2012
New Mexico 2011			Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise, physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies have proven inadequate (R13-14).	Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first.
ASA and ASRA 2010	Guidelines focus specifically on interventional diagnostic procedures including, but not limited to, diagnostic joint block (i.e., facet and sacroiliac), diagnostic nerve block (e.g., peripheral or sympathetic, celiac plexus and hypogastric), provocative discography, or neuraxial opioid trials. Celiac plexus blocks using local anesthetics with or without steroids may be used for the treatment of pain secondary to chronic pancreatitis. Lumbar sympathetic blocks or stellate ganglion blocks may be used as components of the multimodal treatment of CRPS if used in the presence of consistent improvement and increasing duration of pain relief. Sympathetic nerve blocks should not be used for long-term treatment of non-CRPS neuropathic pain. Medial branch blocks may be used for the treatment of facet-mediated spine pain. Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.	Subcutaneous peripheral nerve stimulation: Subcutaneous peripheral nerve stimulation may be used in the multimodal treatment of patients with painful peripheral nerve injuries who have not responded to other therapies. Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies. It may also be considered for other selected patients (e.g., those with CRPS, peripheral neuropathic pain, peripheral vascular disease, or postherpetic neuralgia). Shared decision making regarding spinal cord stimulation should include a specific discussion of potential complications associated with spinal cord stimulator placement. A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device. TENS: TENS should be used as part of a multimodal approach to pain management for patients with chronic back pain and may be used for other pain conditions (e.g., neck and phantom limb pain).	These Guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of chronic pain and pain-related problems. The Guidelines recognize that the management of chronic pain occurs within the broader context of health care, including psychosocial function and quality of life. The article recommends 11 opioid alternatives.	Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, noninflammatory low back pain.
Chou 2009
Fine 2009
Utah 2009			Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., physical therapy), should be tried and the outcomes of those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies have proven inadequate (R16).
Wheeling-Ohio [N/A]			not be the preliminary or primary course of treatment designed to relieve a patient’s reported pain. Whenever possible, emergency department staff should consider the use of non-opioid medications and other alternative pain-relief treatments before opioid analgesic medications are prescribed to treat a patient’s reported pain. Whenever possible and appropriate, emergency department personnel should recommend non-opioid medication such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and nerve blocks to treat a patient’s reported pain. Whenever possible and appropriate, emergency department personnel should also consider the use of other therapies and treatments that do not require medication to treat a patient’s reported pain. Opioid analgesic medications should only be prescribed after these alternative treatment options have been thoroughly considered and when the emergency department personnel has determined that an opioid analgesic medication is medically necessary to treat a patient’s reported pain.

3.2.6 Complementary and Alternative Medicine (CARA)

	3.2.6 Complementary and Alternative Medicine (CARA)	3.2.6.1 Acupuncture
Arnsteen 2017	Physical and cognititve behavioral; therapeutic exercises, salves, supplements, and self-management techniques, mind-body therapies	Auricular point acupressure provides significant prain relief to some older adults with low back pain
Bruce 2017		Clinicians might consider a trial of acupuncture for chronic pain (weak, moderate). Values and preferences: This recommendation places a relatively high value on the reduction of symptoms and few undesirable effects. Remark: Evidence to date is available only for acupuncture in the absence of amitriptyline and among PLWH with poorer health in the era before highly active antiretroviral therapy.
Colorado 2017	Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed. Alternative treatments, including early mobilization and physical therapy, can improve return to function and decrease disability and should be used as first-line agents in the treatment of this complaint (R7). See (R12) for a full list of clinical recommendations.
Cornelius 2017	Implementing basic comfort, consider music, imagery, distractions, altering the environment to provide comfort (lighting, noise, privacy, position changes). Some older adults may use prayer and meditation.	Acupuncture, massage, or cold application as adjuncts to postoperative pain relief has limited evidence to recommend or discourage use for adults.
Horgas 2017	Older adult patients should be prescribed nonpharmacologic treatment, separately or in combination with drug therapy, to achieve effective pain management	There is evidence to support the use of acupuncture, mindfulness meditation, massage, TENS, and cognitive behavioral therapy to treat pain.
Manchikanti 2017
Munzing 2017	Nonpharmacologic (eg, physical therapy, heat, ice, massage, rest, exercise, meditation, cognitive-behavioral therapy, treating comorbid conditions); devices (eg, transcutaneous electrical nerve stimulation, implanted neurostimulators)
New Jersey 2017	Hospitals across the state should be encouraged to look at the success of the ALTO project at St. Joseph’s Hospital in Paterson and either adopt it, or take a hard look at alternatives to pain management in their facilities and adopt methods that will lead to a dramatic lessening of opioid prescribing/dispensing (R25).
Oregon 2017	Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate (R6).
Qaseem 2017	Acute, Subacute: clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation (R1); Chronic: should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (R2).  Chronic: for non-responders, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy; opioids last option (R3).
Tehama 2017	Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. Non-opioid pharmacologic therapy (such as nonsteroidal anti-inflammatories (NSAIDs), acetaminophen, anticonvulsants, and serotonin and norepinephrine reuptake inhibitors (SNRIs)) should be used when benefits outweigh risks and should be combined with non-pharmacologic therapy
VA/DOD 2017	Recommend non-pharm over pharm (R1); Recommend against long-term opioid therapy for chronic pain (R1); for pharm, recommend non-opioid (R1)
Cooney 2017		Neither recommends nor discourages acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence). There is insufficient evidence to recommend the use of acupuncture
Chou 2016	The panel recommends that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence).	The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence).
Deng 2016
Dowell 2016	Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain (R1)
Erie 2016	Non-Pharmacologic Treatment should be considered as first-line therapy for acute pain unless the natural history of the cause of pain or clinical judgement warrants a different approach. These therapies often reduce pain with fewer side effects and can be used in combination with non-opioid medications to increase likelihood of success.                              1) Somatic Pain • Acetaminophen • Non-steroidal anti-inflammatory drugs (NSAIDS) • Corticosteroids • Alternatives include: Gabapentin/Pregabalin, skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors and tricyclic antidepressants. 2) Visceral Pain • Acetaminophen • NSAIDS • Corticosteroids                                       • Alternatives include the following: Dicyclomine, serotonin-norepinephrine reuptake inhibitors, topical anesthetics and tricyclic antidepressants.                                                                        3) Neuropathic Pain • Gabapentin/Pregabalin • Serotonin and norepinephrine reuptake inhibitors • Tricyclic antidepressants • Alternatives include: other antiepileptics, Baclofen, Bupropion, low-concentration Capsaicin, selective serotonin reuptake inhibitors and topical Lidocaine	Non-Pharmacologic Treatment should be considered as first-line therapy for acute pain unless the natural history of the cause of pain or clinical judgement warrants a different approach. These therapies often reduce pain with fewer side effects and can be used in combination with non-opioid medications to increase likelihood of success. Examples may include, but are not limited to: Massage therapy, tactile stimulation, acupuncture/acupressure, chiropractic adjustment, manipulation, and osteopathic neuromuscular care
Paice 2016		Massage, acupuncture, music (Evidence-based; benefits outweigh harms; evidence quality: low; strength of recommendation: weak)
West Virginia 2016	Recommended before opioid usage (R15).
Bhatnagar 2015	Neurolytic celiac plexus block, Splanchnic nerve block, neurolytic superior hypogastric plexus block, vertebroplasty, kyphoplasty. See above for scoring and recommendations
Kampman 2015
Mai 2015	Nonpharmacologic treatments, such as cognitive-behavioral therapy, activity coaching, and graded exercise, are also encouraged
Marin 2015
Monterey 2015
Washington 2015	CBTs, mindfulness, meditation, yoga, relaxation, biofeedback, activity coaching, graded exercise, Identify existential distress, seek meaning and purpose in life, promote patient efforts aimed at increased functional capabilities (R14). Pain is a multidimensional experience; so therefore, pain management is most effective when a multimodal approach is utilized (Table 1). In addition to medication, therapies should include physical activation and behavioral health interventions (such as cognitive behavioral therapy, mindfulness, coaching, patient education, and self-management).
Chou 2014
Hegmann 2014
North Carolina 2014	Early treatment with non-pharmacologic interventions including physical therapy, exercise, and cognitive behavioral techniques, should be employed whenever possible. Other treatment modalities including minor interventions such as anesthetic and steroid joint injections, cutaneous stimulators, topical anesthetics, and local therapies employing heat, massage, and manipulations should be considered before using opiates (R9).	An ancient oriental medical technique where needles are placed at anatomic points along the 12 meridians of the body. Oriental medical theory, passed down for thousands of years, states that vital energy (chi) flows through the body along these 12 meridians. Although current medicine does not fully understand how acupuncture works, we do know from functional MRI studies that acupuncture activates/deactivates particular areas of the brain during needling. In addition, it is known that endorphin (endogenous opioid) levels rise during needling. Clinically, acupuncture has been successfully employed to treat a variety of disorders including opioid addiction (198).
Oklahoma 2013
ASA 2012	Whenever possible, anesthesiologists should use multimodal pain management therapy: NSAIDs, COXIBs, or acetaminophen calcium channel antagonists
Hawaii 2012	With consideration to their inherent risks, alternative and effective pharmacological interventions for acute pain include non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, and nerve blocks (e.g. for dental pain). Non-pharmacological therapies, such as fracture immobilization and proper elevation of injured extremities, may obviate the need for additional pain medications. Short-acting opioid analgesics such as hydrocodone, immediaterelease oxycodone, and hydromorphone may be considered as adjuncts to relieve acute pain when the severity of the pain warrants their use or when non-opioid medications have not provided adequate relief from pain (R2).
San Diego 2012
New Mexico 2011	Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise, physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies have proven inadequate (R13-14).	Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., acupuncturist, chiropractor, doctor of oriental medicine, exercise physiologist, massage therapist, pharmacist, physical therapist, psychiatrist, psychologist), should be tried and the outcomes of those therapies documented first.
ASA and ASRA 2010	These Guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of chronic pain and pain-related problems. The Guidelines recognize that the management of chronic pain occurs within the broader context of health care, including psychosocial function and quality of life. The article recommends 11 opioid alternatives.	Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, noninflammatory low back pain.
Chou 2009
Fine 2009
Utah 2009	Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., physical therapy), should be tried and the outcomes of those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies have proven inadequate (R16).
Wheeling-Ohio [N/A]	Opioid analgesic medications should not be the preliminary or primary course of treatment designed to relieve a patient’s reported pain. Whenever possible, emergency department staff should consider the use of non-opioid medications and other alternative pain-relief treatments before opioid analgesic medications are prescribed to treat a patient’s reported pain. Whenever possible and appropriate, emergency department personnel should recommend non-opioid medication such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and nerve blocks to treat a patient’s reported pain. Whenever possible and appropriate, emergency department personnel should also consider the use of other therapies and treatments that do not require medication to treat a patient’s reported pain. Opioid analgesic medications should only be prescribed after these alternative treatment options have been thoroughly considered and when the emergency department personnel has determined that an opioid analgesic medication is medically necessary to treat a patient’s reported pain.

3.2.7 Other Considerations

	3.2.7.1 Patient Engagement	3.2.7.1.1 Discussion of goals and expectations	3.2.7.2 Risk Assessment and Mitigation	3.2.7.2.1 Screening and Monitoring (mostly used for screening, monitoring is below)	3.2.7.2.2 Management of high-risk populations who receive opioids in the course of medical care, other than for pain management (CARA)
Arnsteen 2017				Assessment strategies: secreening for pain and a comprehensive assessment. Techniques are also included for older adults with cognitive impairment and nonverbal older adults. For persistenet pain use the PEG tool. The Short Form of the Mini-Mental State Examination, Mini-Cog, The Clock Drawing Test and other brief cognitive screens are validated, clinically useful tools to identify cognitive impairment. To overcome impairments in vision and hearing, patients who use glasses or hearing aids should use them during these screens. Showing older adults the assessment tool with large, simple bold lettering is suggested. A family member or interpreter is also recommended. Additional important assessment aspects include: pain history, physical examination, anxiety/fear and depression.
Bruce 2017		An “opioid patient–provider agreement (PPA)” is recommended as a tool for shared decision making with all patients before receiving opioid analgesics for chronic pain (strong, low). Remark: PPAs consist of 2 components: informed consent and a plan of care. When a patient’s behavior is inconsistent with the PPA, the provider must carefully consider a broad differential diagnosis.		All PLWH should receive, at minimum, the following standardized screening for chronic pain: How much bodily pain have you had during the last week? (none, very mild, mild, moderate, severe, very severe) and Do you have bodily pain that has lasted for more than 3 months? (strong, low). Routine monitoring of patients prescribed opioid analgesics for the management of chronic pain is recommended (strong, very low). Remark: Opioid treatment agreements, urine drug testing (UDT), pill counts, and prescription drug monitoring programs are commonly used tools to safeguard against harms.
Colorado 2017		Patients who receive opioids should be educated about their side effects and potential for addiction, particularly when being discharged with an opioid prescription (R9).		Prior to prescribing an opioid, physicians should perform a rapid risk assessment to screen for abuse potential and medical comorbidities. Alternative methods of pain control should be sought for patients at increased risk for abuse, addiction, or adverse reactions. Emergency physician groups should strongly consider tracking, collecting, and sharing individual opioid prescribing patterns with their clinicians to decrease protocol variabilities (R7). Patients receiving controlled medication prescriptions should be able to verify their identity (R9).
Cornelius 2017		Appropriate education with the elderly patient, clinican, and family can decrease postoperative pain.		A physical examination to focus on reported location of pain and existence of pathological conditions know to be painful; congnitive satus - a brief cognitive screen; anxiety/fear and depression, impact of pain on ability to perform postoperative routines. Pain history, past pain experiences and knowledge and attitudes and beliefs; current knowledge of pain management and medication history. Older adults should be closely monitored for opioid drug adverse effects.
Horgas 2017		Patients must be prescribed opioids based on clearly defined therapeutic goals.		Many efforts have been initiated to reduce this problem, including the development of drug monitoring programs, abuse-deterrent drug formulations, and educational programs. In 2016, the Centers for Disease Control and Prevention published 12 recommendations for prescribing opioid drugs to patients with noncancer pain.25 Broadly, the recommendations are aimed at helping providers to (1) determine when to initiate opioids and guidance on the selection and dosing of opioids; (2) determine whether the treatment is beneficial and decide whether to continue opioid therapy; and (3) conduct risk assessments and address harm that occurs as a result of opioid use
Manchikanti 2017		Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: Level I-II; Strength of Recommendation: Moderate) Obtain a robust opioid agreement, which is followed by all parties. (Evidence: Level III; Strength of Recommendation: Moderate) Understand and educate the patients of the effectiveness and adverse consequences. (Evidence: Level I; Strength of Recommendation: Strong)		Screening for opioid abuse to identify opioid abusers. (Evidence: Level II-III; Strength of Recommendation: Moderate) Utilization of urine drug testing (UDT). (Evidence: Level II; Strength of Recommendation: Moderate) Establish appropriate physical diagnosis and psychological diagnosis if available. (Evidence: Level I; Strength of Recommendation: Strong) Consider appropriate imaging, physical diagnosis, and psychological status to collaborate with subjective complaints. (Evidence: Level III; Strength of Recommendation: Moderate) Establish medical necessity based on average moderate to severe (≥ 4 on a scale of 0 – 10) pain and/or disability. (Evidence: Level II; Strength of Recommendation: Moderate) Utilization of prescription drug monitoring programs (PDMPs). (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) Monitor for adherence, abuse, and noncompliance by UDT and PDMPs. (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) Periodically assess pain relief and/or functional status improvement of ≥ 30% without adverse consequences. (Evidence: Level II; Strength of recommendation: Moderate) Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated. (Evidence: Level I; Strength of Recommendation: Strong) May continue with monitoring with continued medical necessity, with appropriate outcomes. (Evidence: Level I-II; Strength of Recommendation: Moderate)
Munzing 2017		The physician should document an assessment as specific as possible (eg, lumbar radiculopathy rather than back pain) and goal setting (eg, maximizing function while minimizing risk, increasing the ability of the patient to work or perform specific activities, or tapering the medication dosages as tolerated).		A thorough history, physical examination, and evaluation is needed to reach as specific a diagnosis as possible. One must weigh the potential benefit of a treatment with the potential risk. CURES or other PDMP • Urine drug screening • Laboratory testing: As indicated; patient specific • Updated brief history, examination, assessment • Morphine equivalent dosing (MED) calculation and monitoring
New Jersey 2017
Oregon 2017		Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy (R6).		When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs (R8).
Qaseem 2017		For opioid in non-responders, discussion with patients of known risks and benefits (R3)
Tehama 2017		Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.		When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. Discuss planned use of precautions to reduce risks, including use of prescription drug monitoring program (PDMP) information and urine drug testing. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months. Discuss the importance of periodic reassessment to ensure opioids are helping to meet patient goals and to allow opportunities for opioid discontinuation and consideration of additional non-pharmacologic and non-opioid pharmacologic treatment options if opioids are not effective or are harmful. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently.
VA/DOD 2017				For patients less than 30 years of age currently on long-term opioid therapy, we recommend close monitoring and consideration for tapering when risks exceed benefits (R6); We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy: ongoing, random urine drug testing, prescription drug monitoring programs (PDMP), monitoring for overdose potential and suicidality, providing overdose education, prescribing of naloxone rescue and accompanying education(R7); Recommend assessing suicide risk when considering initiating or continuing long-term opioid therapy (R8); Recommend evaluating benefits of continued opioid therapy and risk for opioid-related adverse events at least every three months. (R9) (w/patient?); Recommend more frequent monitoring for adverse events including opioid use disorder and overdose (R11)	We recommend against long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose (R6); We recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder (R17); Recommend interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior (R16) [CAVEAT: THIS IS ABOUT PAIN]
Cooney 2017		Clinicians should provide patient- and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for management of postoperative pain, and document the plan and goals for postoperative pain management (strong recommendation, low-quality evidence). Clinicians provide education to all patients (adults and children) and primary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge (strong recommendation, lowquality evidence).		Clinicians conduct a preoperative evaluation including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimes and responses, to guide the perioperative pain management plan (strong recommendation, low-quality evidence).
Chou 2016		The panel recommends that clinicians provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for management of postoperative pain, and document the plan and goals for postoperative pain management (strong recommendation, low-quality evidence). The panel recommends that clinicians provide education to all patients (adult and children) and primary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge (strong recommendation, low-quality evidence).		The panel recommends that clinicians conduct a preoperative evaluation including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan (strong recommendation, low-quality evidence).
Deng 2016
Dowell 2016		Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients (R2); Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy (R3)		Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) (R9); clinicians should use urine drug testing before starting opioid therapy (R10);	Offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder (R12)
Erie 2016		Upon determining the symptoms fit the definition of acute pain, both the provider and patient should discuss the risks/benefits of both pharmacologic and non-pharmacologic therapy. The provider should educate and develop a treatment plan together with the patient that includes: Measurable goals for the reduction of pain,  use of both pharmacologic and non-pharmacologic therapies, with a clear path for progression of treatment,  mutually understood expectations for the degree and the duration of the pain during therapy. Goal: Improvement of function to baseline or pre-injury status as opposed to complete resolution of pain, reassure the patient that: acute pain usually improves within a few days or weeks with return to normal activity, in most cases acute pain is not due to serious disease or damage, and remaining as active as possible and limiting bedrest will help maximize recovery.		For assessing patients presenting with acute pain, in addition to a proper medical history and physical exam, initial considerations should include: • Location, intensity and severity of the pain and associated symptoms • Quality of pain e.g. somatic (sharp or stabbing), visceral (ache or pressure) and neuropathic pain (burning, tingling or radiating) • Psychological factors, including personal and/or family history of substance use disorder. Check the NYSDOH prescription monitoring database for all patients who may be receiving opioid prescription, regardless of the number of days that medication is prescribed.
Paice 2016				Clinicians should screen for pain at each encounter. Screening should be performed and documented using a quantitative or semiquantitative tool. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong) Clinicians should conduct an initial comprehensive pain assessment. This assessment should include an in-depth interview that explores the multidimensional nature of pain (pain descriptors, associated distress, functional impact, and related physical, psychological, social, and spiritual factors) and captures information about cancer treatment history and comorbid conditions, psychosocial and psychiatric history (including substance use), and prior treatments for the pain. The assessment should characterize the pain, clarify its cause, and make inferences about pathophysiology. A physical examination should accompany the history, and diagnostic testing should be performed when warranted. (Informal consensus; benefits outweigh harms; evidence quality: insufficient strength of recommendation: moderate)
West Virginia 2016		Establishing a “Patient and Provider Agreement” (previously referred to as a patient contract, consent, or agreement) is an invaluable tool to ensure a mutual commitment from the patient and the provider(s) to achieve and maintain treatment goals, while also stating any reasons for agreement termination (R6). Before starting and periodically during opioidtherapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy (R23*).		All patients being considered for chronic opioid therapy should be screened for risk of substance misuse. Screen for this risk before prescribing opioids. Importantly, patients who have been taking opioids for long periods of time should also be routinely screened (R5). Urine drug screening/testing is important in the monitoring of compliance of prescribed medications and detecting the use of illicit substances (R10). Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients at least every3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids (R23*)
Bhatnagar 2015		• Written, informed consent preferably in patient's own language explaining the goals of the procedure, what to expect, financial implications, probable side-effects, and complication is a prerequisite. Patients should be asked about any queries if they have which should be answered and documented. Consultation regarding preferred site of catheter exit and implantable pump should also be sought and respected		• A detailed history and physical examination tailored towards etiology, quality, and putative anatomical transmission pathways involved • Accurate documentation of pain location, frequency, intensity, and its effect on QoL must precede interventions • Presence and degree of any neurological deficits, co-morbidities, drug allergies as well as any contraindications to interventions should be sought and well-documented at this stage • Site-specific inspection at the intended puncture site to rule out any local infection or bed sores is a must and an absolute contraindication if found so. Patient's ability to lie in prone position for the duration of block should also be assessed
Kampman 2015				First, clinical priority should be given to identifying and making appropriate referral for any urgent or emergent medical or psychiatric problem(s), including drug-related impairment or overdose. Completion of the patient’s medical history should include screening for concomitant medical conditions, including infectious diseases (hepatitis, HIV, and tuberculosis [TB]), acute trauma, and pregnancy. A physical examination should be completed as a component of the comprehensive assessment process.
Mai 2015				Use of chronic opioid therapy requires regular monitoring and documentation, such as screening for risk of comorbid conditions with validated tools, checking the Prescription Monitoring Program database, assessing function, and administering random urine drug tests. Preliminary data from the Washington state Prescription Monitoring Program (PMP) have suggested that substantial numbers of newly injured workers received opioids or other controlled substances in the 60 days before injury. For this reason, providers should check the PMP before prescribing opioids for new injuries or occupational diseases.
Marin 2015		Patients being offered opioids should be made aware that opioids are the leading cause of drug overdose deaths nationally, can cause adverse outcomes to patients or to others who may misappropriate the medication, and can cause harm if not managed safely. It is appropriate for pharmacists to have educational conversations with patients on potential side effects of opioids, drug-drug interactions, and adverse effects. With patients receiving over 100 mg /day, pharmacists should feel enabled to initiate discussions with clinician and patient about naloxone. Pharmacists should educate patients regarding safe storage and disposal of medications. Patients should receive education and information on safe storage and disposal or return of controlled substances. Materials should include information on lock-boxes for safe in-home storage of prescriptions. (R5).		Before considering chronic opioid therapy, clinicians should gain a clear understanding of the pain condition and document a history, including current medications, prior pain treatment and results, along with a relevant and specific physical examination. The initial evaluation should also include documentation of the patient’s mental health and substance use history, including review of the CURES system. The history should include a functional description of limitations on the patient's activities due to pain. Clinicians should consider using a validated screening tool to determine the patient’s risk for harmful drug-related behavior. Appropriate screening and testing should be completed before, and not after starting a trial of opioids (R3). Pharmacists who dispense medications have corresponding responsibility to ensure the prescription is legal and not for purposes of abuse. Pharmacists may employ screening guidelines to trigger communications with clinicians to verify prescription orders (R5). Clinicians should reassess patients on chronic opioid therapy periodically and as warranted by changing circumstances. Monitoring should include documentation of response to therapy, adverse events and adherence to prescribed therapies. Clinicians should consider increasing the frequency of ongoing monitoring as well as referral for specialty care, including psychiatric and addiction experts for patients at high risk for harmful drug-related behavior. Monitoring may include periodic review of CURES database, urine or saliva drug screening or pill counts (R3).
Monterey 2015				Patients receiving narcotic pain medications should be asked about any history of abuse or addiction to alcohol, prescription drugs, or illegal drugs. Chronic: Perform a risk evaluation using the Opioid Risk Tool or other standard tool. 3. Initiate a Medication Management Agreement. 4. Run a CURES report for all patients:  Requiring narcotic pain medication for more than 30 days  Entering into a medication management agreement  With non-cancer chronic pain requiring pain medication based on a pain specialist’s recommendation. A CURES report will be added to the patient’s chart every 90 days.  With a history suggesting “red flags” for controlled substance medication abuse, misuse, or diversion.The patient should be seen monthly by the PCP during chronic pain management using opioids. A random drug screen should be run every 3-6 months with the identification of CURES discrepancies or “red flags”.
Washington 2015		Providing quality treatment for your patients is critical, and so is educating them about the risks of taking opioid medications. Resources that can help you provide this education are listed on page 76 and 77.
Chou 2014		The panel recommends that clinicians educate and counsel patients prior to the first prescription of methadone about the indications for treatment and goals of therapy, availability of alternative therapies, and specific plans for monitoring therapy, adjusting doses, potential adverse effects associated with methadone, and methods for reducing the risk of potential adverse effects and managing them (strong recommendation, low-quality evidence).		When considering initiation of methadone, the panel recommends that clinicians perform an individualized medical and behavioral risk evaluation to assess risks and benefits of methadone, given methadone’s specific pharmacologic properties and adverse effect profile (strong recommendation, low-quality evidence). The panel recommends that clinicians obtain an ECG prior to initiation of methadone in patients with risk factors for QTc interval prolongation, any prior ECG demonstrating a QTc >450 ms, or a history suggestive of prior ventricular arrhythmia. An ECG within the past 3 months with a QTc <450 ms in patients without new risk factors for QTc interval prolongation can be used for the baseline study (strong recommendation, low-quality evidence). The panel recommends that clinicians obtain urine drug screens prior to initiating methadone and at regular intervals in patients prescribed methadone for opioid addiction (strong recommendation, lowquality evidence). The panel recommends that patients prescribed methadone for chronic pain who have risk factors for drug abuse undergo urine drug testing prior to initiating methadone and at regular intervals thereafter. The panel recommends that patients receiving methadone be monitored for common opioid adverse effects and toxicities and that adverse effects management be considered part of routine therapy (strong recommendation, moderate-quality evidence).
Hegmann 2014				No quality studies assess the utility of a history and physical examination. Nevertheless, the Panel’s consensus recommendation is that a careful history and physical examination are highly important for appropriate pain management and consideration of opioid prescriptions regardless of pain acuity. Urine Drug Screenings are recommended.
North Carolina 2014		The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity (R9).		After opioid trial is initiated: The physician should explain that progress will be carefully monitored for benefit and harm in terms of the effects of opioids on the patient’s level of pain, and on the patient’s physical, functional and psychosocial activities. Attention will be focused on adverse events and risks to safety (R11). The physician should regularly review the patient’s progress, including any new information about the etiology of the pain or the patient’s overall health and level of activities (R12). Drug testing is an important monitoring tool because self-reports of medication use and behavioral observations are not always reliable. If necessary, initial testing can be followed with more specific techniques, including gas chromatography/mass spectrometry (GC/MS) or other chromatographic tests  (R13). Assessment of the patient’s personal and family history of alcohol or drug abuse and relative risk for medication misuse or abuse should be part of the initial evaluation (R7). All patients should be screened for depression and other mental health disorders as part of risk evaluation. Information provided by the patient is a necessary but insufficient part of the evaluation process. Reports of previous evaluations and treatments should be confirmed by obtaining records from other providers. Patients occasionally provide fraudulent records. Obtaining a toxicology screen, such as a urine drug screen, is a useful tool in the setting of risk assessment prior to prescribing opioids (R8).
Oklahoma 2013		When opioids are prescribed for treatment of acute pain, the patient should be counseled to store the medications securely and never to share with others. In order to prevent nonmedical use of the medications, it is also recommended that patients dispose of medications when the pain has resolved (R4). The patient should be informed of the risks, benefits, and terms for continuation of opioid treatment, ideally using a written and signed treatment agreement (R9).		The health care provider should screen for risk of abuse or addiction before initiating opioid treatment (R6).
ASA 2012		Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, patient and family education regarding their important roles in achieving comfort, reporting pain, and in proper use of the recommended analgesic methods. Patient education for optimal use of PCA and other sophisticated methods, such as patient-controlled epidural analgesia, might include discussion of these analgesic methods at the time of the preanesthetic evaluation, brochures and videotapes to educate patients about therapeutic options, and discussion at the bedside during postoperative visits.		A directed pain history, a directed physical examination, and a pain control plan should be included in the anesthetic preoperative evaluation.
Hawaii 2012		Provide information about the risks of opioid analgesics, including overdose and addiction, along with information about proper storage and disposal to those receiving a prescription (R6).		Patients with a history of substance abuse are at increased risk for developing opioid addiction when prescribed opioid analgesics for acute pain. Numerous validated screening tools are available, including the DAST-10 (Drug Abuse Screening Test) and the Opioid Risk Tool. Alternatively, the single question, “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” was found to be 100% sensitive and 74% specific for the detection of a drug use disorder compared to DAST-10 (R3). Hospitals are required by law to provide a medical screening examination to determine if a patient has an emergency medical condition. The law does not require physicians to use opioid analgesics to treat pain (R7).
San Diego 2012				Conduct a Pain Assessment Utilizing a Standard Tool / Opioid Risk Tool • There are various Tools available for Initial Assessment, upon initiating Pain Agreement, and for On Going Follow Up and Monitoring  Use Drug Screens • Use as an initial screening tool when considering prescribing an opioid. • Consider for all patients with a pain agreement at the time of initial pain evaluation, at 3 months, and randomly at your discretion considering each individual risk and benefit profile. Evaluate to see that prescribed medications are positive. If the patient is not positive for the medications prescribed then the medication is either (a) not being used safely such as overuse at the beginning of the month and running out early, or (b) being diverted. • Evaluate for illegal drugs or drugs that were not prescribed. • Note that the Pain Agreement devised by the San Diego County Prescription Drug Abuse Medical Task Force states that use of illegal drugs is grounds to discontinue pain medication and refer to addiction medicine or other appropriate specialist. (R4).
New Mexico 2011		When opioid medications are prescribed for treatment of acute pain, the patient should be counseled to store the medications securely, not share with others and to dispose of properly when the pain has resolved in order to prevent non-medical use of the medications (R11). The patient should be informed of the risks and benefits and any conditions for continuation of opioid treatment, ideally using a written and signed treatment agreement (R18).		Use a screening tool to assess the patient’s risk of misuse prior to prescribing an opioid medication long-term for chronic pain (R14). Providers should consider performing drug screening on randomly selected visits and any time aberrant behavior is suspected (R27). Once a stable dose has been established (stable chronic dose period), regular monitoring should be conducted at face-to-face visits during which treatment goals, analgesia, activity, adverse effects are monitored. Patients should be monitored for aberrant behavior (tools include drug screening and prescription drug monitoring program report surveillance).
ASA and ASRA 2010				The Task Force recognizes that conducting a history and physical examination and reviewing diagnostic studies by a physician are well established as essential components of each patient’s evaluation. Although no controlled trials were found that address the impact of conducting a history (e.g., reviewing medical records and patient interviews), physical examination, or psychologic or behavioral evaluation, numerous studies address the identification of certain health disorders (e.g., diabetes, multiple sclerosis, or posttraumatic injury) that are associated with specific pain conditions
Chou 2009		There is insufficient evidence (no studies that met inclusion criteria) to determine effectiveness of different patient education methods or clinician advice for improving outcomes associated with chronic opioid therapy. The only study on clinical outcomes associated with signing an opioid contract retrospectively evaluated 20 patients on chronic opioid therapy with a history of substance abuse279. It found that signing of an opioid contract was not associated with a “successful outcome,” though this outcome was not defined. Of the nine patients who signed a contract, four subsequently violated it.		One prospective derivation study found that the COMM may be useful for identifying drugrelated behaviors in patients prescribed opioids for chronic noncancer pain. However, the COMM is a relatively weak predictor and results require validation in other populations and settings. There is insufficient evidence from other studies to determine the diagnostic accuracy or other screening instruments for identifying aberrant drug-related behaviors, due to methodological shortcomings. All studies used poorly standardized or described methods for identifying aberrant drug-related behaviors and did not evaluate the seriousness of the identified behaviors. No study has evaluated the utility of formal screening instruments compared to informal clinician assessments (level of evidence: low).
Fine 2009
Utah 2009		When opioid medications are prescribed for treatment of acute pain, the patient should be counseled to store the medications securely, to not share with others, and to dispose of medications properly when the pain has resolved in order to prevent non-medical use of the medications. The patient should be informed of the risks and benefits and any conditions for continuation of opioid treatment, ideally using a written and signed treatment agreement (R10).		The provider should screen for risk of abuse or addiction before initiating opioid treatment (R10). Once a stable dose has been established (maintenance period), regular monitoring should be conducted at faceto-face visits during which treatment goals, analgesia, activity, adverse effects, and aberrant behaviors are monitored (R10).
Wheeling-Ohio [N/A]		Patients should be informed of the risks of taking opioid analgesics and be reminded to take them as prescribed, not more frequently or in greater quantities.  Respiratory depression is more common with use of alcohol, benzodiazepines, antihistamines, and barbiturates. Patients should be reminded to avoid medications that are not part of their treatment plan because they may worsen side effects and increase the risk of overdose.		Before writing a discharge prescription for opioid analgesics, emergency department staff should asses the patient for the risk of opioid misuse or addiction. This assessment should include the use of screening tools and available prescription monitoring program databases. The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide a medical screening examination to determine whether an individual presenting at an emergency department has an emergency medical condition. If the hospital determines that a patient has an emergency medical condition, the hospital must provide treatment as may be required to stabilize the patient’s medical condition. EMTALA, however, does not require the use of opioid analgesics to treat pain. ED prescribers may apply their professional judgment to determine whether prescribing opioid analgesics for pain is the appropriate course of treatment. Prescription monitoring program databases contain important information on the patient’s controlled substance prescription history. This information should be accessed, whenever possible, when emergency department personnel are deciding whether to prescribe opioid analgesic medications in the emergency department to treat the patient’s reported pain.

 

Footnotes

¹  Includes Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, and the District of Columbia

²  Includes Norton, VA; Martinsville, VA; Galax, VA; Emporia, VA; Franklin City, VA; Owsley, KY; Bell, KY; Whitley, KY; Hardin, IL; Lexington, VA; Walker, AL; Covington, VA; Floyd, KY; Franklin, AL; Colonial Heights, VA; Ware, GA; Pike, KY; Clay, KY; Saline, IL; Forrest, MS; Leslie, KY; Perry, KY; Colbert, AL; Salem, VA; Waynesboro, VA; Ben Hill, GA; Campbell, TN; Wise, VA; Logan, WV; Haralson, GA; Evangeline, LA; Scotland, NC; Marshall, AL; Clay, TN; Claiborne, TN; Henry, TN; Cocke, TN; Harmon, OK; Breathitt, KY; Dickenson, VA; Pratt, KS; McCracken, KY; Marion, MS; Marion, AL; Butler, MO; Fulton, KY; Tazewell, VA; Danville, VA; Seminole, GA; Fentress, TN. Identified from CDC’s data on opioid prescribing rates per capita.