“Good discussion everyone. This is really such a complex series of problems with complex potential solutions that will require all of us – prescribers, those involved in managing the injured worker’s case, and the patient. It is important to keep the following issues in mind:

1. Initially the goal is relief of chronic pain. Prescribers are poorly informed about how to rx proactively as acute pain becomes chronic pain…a totally different animal. Chronic pain needs a very structured limited treatment plan that, if opiates are included, should be closely and tightly monitored for progress and maintenance of function. Case managers can be helpful keeping the care on track. If doses are escalating, then prescriber may need help implementing an exit strategy to facilitate discontinuation of the opiate sooner rather than later.
2. If a patient has ADDICTION, which is present, studies suggest, in as many as 20% of all patients with chronic pain, choice is not a factor. Addiction is a loss of control diseases and the patient’s dose escalation, albeit with prescriber “assistance” is inevitable. These patients need assistance with their pain but also equally as important, with their addictive disease.
3. Proper assessment for risk of addiction and close monitoring of those at risk could, in the best of all worlds, preempt the inevitable downward spiral in those with addiction and chronic pain.
4. Sedatives including benzodiazepines and carisoprodal (soma) and “z-drugs” (Ambien and the like) should be avoided in patients on opiates.
5. Though far from a panacea, buprenorphine (suboxone) should be considered in those patients requiring opiates for chronic pain (does anyone really require an opiate?)