Education a must for safe delivery of pain management therapies

Health care professionals and patients need to work as a team

Chronic pain sufferers want relief. To achieve their goal, they may misuse pain medication.

"We cannot safely give patients any treatment, let alone medication, that can reliably eliminate their pain if it is a chronic disorder. One of the major problems is the unrealistic expectations many patients have in regard to treating their pain," says Lynn Webster, MD, FACPM, FASAM, a leading expert in the field of pain medicine and addiction and advisor to PainSAFE.

This message needs to be clear for physicians as well. Webster says that when he began his career in the field of pain medicine, he realized he could not always give patients everything they needed for pain relief. He began to redefine realistic expectations for patient safety and best outcomes.

These same issues are addressed by PainSAFE (Pain Safety & Access for Everyone), a new education program available on the website of the American Pain Foundation ( The information focuses on the role of health care consumers, as well as health care professionals, in the safe use of pain management therapies. Information on opioids and implantable pain therapies is available on the website, and a section on over-the-counter pain medication will be ready in January. Educational resources on complementary and alternative medicines are also in the works.

"The website will be evolving — not only in the areas of pain management and the different treatment modalities, but also in regards to providing more resources, tools, and education for the two audiences; the website will continue to expand," says Samantha Libby-Cap, director of PainSAFE.

The mission of PainSAFE is to provide education surrounding the appropriate and safe use of pain management therapies for people affected by pain and health care professionals, thereby helping to reduce risk and improve access to quality pain care. By educating both the consumers and the health care professionals on safety issues, patients will get better care, explains Libby-Cap.

Educational issues addressed

A look at the opioid education modules provides insight into the education provided. For example, the section on the safe use of opioids within the education module for health care professionals advises: "Assess the risk for opioid misuse, provide close monitoring, dose judiciously, and continually reevaluate the benefit of potentially dangerous medications." Eight guidelines are given to minimize safety concerns.

These guidelines include:

— assessing patients for risk of abuse before prescribing a medication and recommended tools for conducting the assessment;

— watching for and treating comorbid mental illness when it occurs, and coordinating care with experts in the field of mental health;

— the cautious use of conventional conversion tables when switching from one opioid to another;

— ways to avoid using benzodiazepines with opioids, especially during sleep hours;

— starting methadone at a very low dose and titrating slowly regardless of whether the individual is opioid-tolerant or not;

— assessing for sleep apnea in patients on high daily doses of methadone or other opioids, and in patients with a predisposition for the sleep disorder;

— providing details to patients on long-term opioid therapy about reducing their opioid dose during upper respiratory infections or asthmatic episodes;

— avoiding the use of long-acting opioid formulations for acute post-operative or trauma-related pain.

A link to safety tools and resources to aid in the education and prevention of addiction or substance abuse is available, as well as six opioid safety steps to give to patients. Information on creating a favorable balance between analgesia and side effects is included, as well as details on what constitutes a legal prescription.

Consumer information includes what happens when patients increase their dosage on their own; try to lower their dosage; or combine opioids with certain medications or alcohol. Also, the safety section includes details on topics to discuss openly with the physician, such as side effects to expect and when to report problems. Patients are educated to discern the differences in tolerance, physical dependence, and addiction to opioids, as well as how to recognize an opioid emergency and take action.

Logs and worksheets for patients to track the use of opioids are available, as well as information on how to safely store the medication so it cannot be accessed by someone who does not have a prescription.

The focus is on safety, risks, and how a patient can properly manage the medication, says Libby-Cap. "I guess the two words you can use to describe PainSAFE [are] 'educating' and 'empowering,'" she adds.

A handout the size of a business card gives consumers six steps for safe opioid use. The card opens to reveal the eight prescribing guidelines for professionals. "The combination builds that communication between the patient and the health care provider, so they both have knowledge," says Libby-Cap.

The focus on providing education on the roles of both the health care professional and the consumer is important, according to Webster. The problem with addiction and overdose deaths is multifactorial, he explains. Patients have ignored the potential danger of the powerful analgesics and fail to follow instructions, taking the medication as they feel they should take it, because they want to get out of pain, says Webster.

"The general attitude of most people with regard to pain medicine is that if you take one and it works, taking two is even better," he says.

Also, with mild analgesics and anti-inflammatory medications, people have grown accustomed to taking one and, if it does not work, taking another. While these medications are reasonably safe, the same practice does not translate to the more powerful pain killers like opioids, explains Webster.

PainSAFE helps educate patients about their responsibilities and provides direction on how to hold them accountable for using the medications as directed and in a safe way. According to Webster, patients and physicians must work together if pain therapies, such as opioids, will continue to be available to treat all the patients who have severe pain.

Based on successful prototype

According to Webster, PainSAFE is a program that evolved from a zero-deaths campaign in Utah launched in 2005. It was started because newspapers reported an epidemic of opioid overdose deaths from prescription drugs.

Webster determined that health care providers in the field of pain medicine needed to address the issue, especially if it was related to their attempt to help patients. Also, at the time, he was president of the Utah Academy of Pain Medicine, and he thought he had a moral responsibility to understand the problem and reverse the trend.

He talked to a wide array of people, read the literature, and conducted clinical research. He learned there were a number of physician errors in prescribing and managing patients using opioids. Also, patients were being harmed, because they were not following instructions and were overusing the medications in an effort to get out of pain. A third problem uncovered was the fact that some medical conditions were particular risk factors for patients who could be harmed from opioids — something not previously known.

He wrote a paper about some of the common problems associated with the overdose deaths and also lectured. This information became part of a program backed by the Utah Department of Health called the "Use Only as Directed" campaign.

"We educated physicians about some of the potential harms of prescribing, how to better manage and monitor our patients, and to instruct them on the appropriate use of medication," says Webster.

The next year, the department of health reported a drop in the death rate from opioid overdose. However, there was no money to support the education program. Therefore, the American Pain Foundation was approached. This organization determined the program should be expanded beyond opioids to ensure that all therapies provided in the field of pain medicine are safe. Webster embraces the concept of looking at what harm has occurred, potential harm, and how to prevent problems in the future. Once the research is completed, physicians and patients must be aware of the problems and how to correct them. In this way, patients will continue to have access to a full, broad spectrum of pain management therapies, says Webster.


• Samantha Libby-Cap, Director of PainSAFE, American Pain Foundation, 201 North Charles Street, Suite 710, Baltimore, MD 21201. E-mail: