Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter A - Chronic Pain Disorder Medical Treatment Guidelines › Section I-2104 - Overview of Chronic Pain Management

Current through Register Vol. 50, No. 6, June 20, 2024
A. It is estimated by the Institute of
					 Medicine that approximately 100 million adults suffer from chronic pain in the
					 United States. The World Health Organizations survey found that 37 percent of
					 adults in 10 developed countries have chronic pain conditions. This overview
					 covers the biopsychosocial nature of chronic pain and a comprehensive plan of
					 care including: functional assessment and goal setting, psychological
					 assessment, medication management, sleep considerations, and active therapy
					 assisted by international pain management procedures with continued therapy
					 afterwards as well as indicated surgery.
B. Chronic pain may develop from persistent
					 acute pain due to neuroplastic changes occurring in the central nervous system.
					 All chronic pain appears to involve a central sensitization which changes the
					 perception of pain. Thus, treatment patterns are aimed at a number of
					 mechanisms contributing to chronic pain.
C. Chronic pain is recognized as a
					 biopsychosocial disease process. Each treatment plan should be individualized
					 with a patient-centered approach addressing the many available treatment
					 combinations. Therefore, all areas of the chronic pain guideline should be
					 considered when developing a treatment plan. This includes: the mandatory
					 psychological evaluation; an active therapy plan; medications specific to the
					 pain process for that patient; continuing functional assessment; complementary
					 medication alternatives, when appropriate; and continued return to work/regular
					 daily activity.
D. Once a patient
					 has been identified as a chronic pain patient, usually three months after an
					 injury when pain persists or when pain persists beyond a reasonable
					 postoperative period, the physician should perform a complete re-evaluation or
					 may refer the patient to a pain specialist or surgeon for consultation. This
					 will assist both the patient and the provider in developing an appropriate
					 treatment plan. Although it is unusual to identify an unknown pathology at this
					 point in the treatment, it is recommended that the provider acknowledge the
					 full complement of patient symptoms and concerns. Repeating or ordering new
					 imaging may be necessary.
E. It is
					 essential that the patient and provider understand the type of pain the patient
					 is experiencing and how the pain affects day-to-day activities. Identifying the
					 presence of neuropathic pain, as well as any sources of nociceptive pain, will
					 assist the patient and provider when choosing medication and other forms of
					 treatment recommended in the guideline.
F. During the chronic pain assessment, it is
					 suggested that all physicians review with the patient their usual activities
					 over several different typical 24-hour periods. This will assist both parties
					 in understanding what functions are not able to be performed by the patient,
					 how significantly sleep is impacted, and whether pain is affecting social and
					 family relationships. This information is also essential for establishing
					 agreed upon functional goals.
G.
					 All chronic pain patients should have psychological evaluations. Patients may
					 merely need assistance with coping mechanisms, and/or anxiety or depression may
					 be caused or exacerbated by chronic pain. Treatment in this area is essential
					 for the chronic pain patient. Cognitive behavioral sessions are frequently
					 effective for these conditions.
H.
					 Review of the current prescribed and over-the-counter medications is an
					 important part of this initial chronic pain evaluation. If the patient has been
					 chronically on opioids, a pain specialist referral should be considered to
					 identify the necessity of the opioids and the proper dose. It is also
					 reasonable to taper opioids in order to determine the patients baseline and how
					 other medications are actually affecting the pain.
1. The following is a general summary of the
					 required elements. A number of other guidelines, including the Centers for
					 Disease Control and Prevention (CDC) for Primary Care Practitioners and Board
					 of Medical Examiners, have confirmed these steps.
a. An opioid trial shall be performed before
					 chronic opioids are determined to be useful for patients. About 50 percent of
					 patients will not be able to tolerate the side effects and/or not show a
					 sufficient increase in function with opioid use. Patients should be aware that
					 this is a trial and like any other medication trial, it will not be continued
					 unless there is sufficient benefit. The average benefit is about a 30 percent
					 decrease in pain. Thus, all other required treatment must be continued during
					 the time period of the chronic opioid trial.
b. Long acting opioids should never be used
					 for acute pain, post-operative pain, or before an opioid trial has been
					 completed. There is no evidence they are more beneficial than short acting
					 opioids, and the trial should begin with short acting opioids.
c. A risk assessment tool, such as the Opioid
					 Risk Tool (ORT) or Screener and Opioid Assessment for Patients with Pain
					 (SOAPP) should be completed to assure the provider that there are no prior
					 elements suggesting substance abuse or, when such elements are present, the
					 physician may choose to refer to a provider with more expertise in substance
					 abuse.
d. Urine drug testing should
					 be done prior to initiating controlled substance.
e. Check the Prescription Monitoring Program
					 (PMP). Follow Louisiana Revised Statutes 40:973, 40:978 and 40:978.3.
f. The psychological evaluation should have
					 been completed and hopefully treatment as appropriate is being
					 continued.
g. A functional history
					 should be taken and functional goals should be set. This needs to be followed
					 throughout all chronic pain treatment to determine if the patient is increasing
					 or decreasing in function.
h. A
					 provider physician agreement must be completed. This is extremely helpful as it
					 reviews for the patient the expectations regarding his/her behavior as well as
					 the expectations regarding when a physician would choose to taper or remove the
					 patient from opioids and what other treatment is expected to continue during an
					 opioid trial.