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54 Chronic pain
care providers, it may be reasonable to refuse medications such as opioids
until a stable doctor–patient relationship is established. One of the most
important tools for long-term pain care provision is the “pain contract.”
Acute care providers should seek to determine whether such a contract has
been arranged for the patient presenting to the ED, and the terms of these
contracts should be respected. In the rare instances when “out-of-contract”
analgesia will be provided by the ED physician, contact with the longitudinal
care provider is critical. In the occasionally inevitable instances for which
the ED becomes the patient’s de facto primary care clinic, the acute care
provider may need to develop (and document for future providers’ reference)
a pain contract (see below).
n Analgesic selections in chronic pain
Patients with chronic pain conditions tend to take analgesics for far longer
than the few days or weeks that suffice for acute pain. Consequently, the
prescribing clinician must be particularly cognizant of the risks of side effects
associated with longer-term use of the medications. Consideration of the
risks may impact medication selection (as risk-to-benefit calculations are
weighed). Alternatively, side effects may prompt the addition of adjunctive
drugs (e.g. stool softeners, anti-dyspeptics) to improve tolerance of pain
relievers.
The fact that an agent or class is used frequently for a given condition
should not lead to an assumption of efficacy. For instance, meta-analysis of
opioid use for chronic low-back pain reveals that this oft-prescribed
approach has only marginal efficacy and incurs a significant risk of
addiction. 2 Similarly, despite their frequent prescription for neuropathic
syndromes, NSAIDs – which are associated with well-described adverse
effects – are generally unhelpful for neuropathy. Even for low-back pain, a
condition in which there is some role for NSAID use in acute care, the chronic
use of these analgesics may have unfavorable risk-to-benefit ratio. Besides
well-publicized ulcer, renal, and cardiovascular risk (see the Arthritis chapter,
p. 94), long-term NSAID use risks abdominal pain, diarrhea, edema, dry
mouth, rash, dizziness, headache, and tiredness. 3 In the past, some experts