Although policies, procedures, and practices related to treating chronic pain are being discussed at national and international levels, there are often challenges to implementing widespread change.

“From healthcare system to healthcare system and practice to practice I have spoken with, it seems that everyone who thinks that the time has come for a ‘pain policy and procedure set’ feels as if they’ve discovered this on their own, when in actuality it has been promoted in many different ways and forms at least over the past 15 to 20 years or more,” said Kevin Zacharoff, MD, of, “This ‘reinventing the wheel’ phenomenon, despite a plethora of writings, guidelines, national meetings, and debates, certainly seems like a ‘Groundhog Day’ phenomenon to me and doesn’t seem to be changing.” 

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Fortunately, Dr. Zacharoff noted that there is a growing body of evidence that has helped to clarify “the misunderstanding of addiction, physical dependence, and analgesic tolerance; the misconception that chronic opioid therapy inevitably causes personality changes … and the lack of information on the correct use of opioid analgesics with regard to titration and management of related side effects.”1

Dr. Zacharoff offered some of his own clinical perspectives on this growing body of evidence. He said in addition to arriving at a diagnosis for the cause of a patient’s pain, it is important to “address any comorbid conditions, including probable substance use disorders and other psychiatric illness.”

Discussing psychiatric illness, Dr. Zacharoff explained that a complete psychological assessment, including personal and family history of substance use, is integral to treating patients with chronic pain. He urged clinicians to discuss patient-centered urine drug testing with all patients. A psychological assessment should also include risk, he explained.

“A sensitive and respectful assessment of risk should be done with available tools and should not be seen in any way as diminishing a patient’s complaint of pain or reliability,” Dr. Zacharoff said. 

Obtaining informed consent is also important, Dr. Zacharoff noted, adding that it is imperative that clinicians “educate the patient about the proposed treatment plan with opioids including: anticipated benefits, foreseeable risks, and concerns at a level appropriate to the individual patient.”

Dr. Zacharoff explained that a treatment agreement is also key. Such agreements should incorporate the expectations and obligations of both the patient and the treating practitioner. 

Also integral to treating the patient with chronic pain is a pre- and postintervention assessment. 

“Initiation of opioid therapy for patients in this setting should be considered a ‘trial’ of therapy by both the clinician and patient,” Dr. Zacharoff said. “Without prior assessment of pain level and function, it would be impossible to measure progress.” 

This article originally appeared on MPR