UCSF pain experts answer the pain management questions they hear most frequently below.
YES, integrative medicine can address a myriad of symptoms. Therefore, integrative medicine should be considered in any pain management plan.
Yes. Acupuncture has good evidence for improving pain of various kinds (perioperatively, cancer-related, chronic pain), as well as other symptoms, and an excellent adverse events profile. Acupuncture is usually viewed by patients as a relaxing and enjoyable experience.
Similarly, guided imagery has shown to improve pain in patients using it. Streaming guided imagery is available through the Osher Center for patients at UCSF Health.
The number of opioid tablets on which to discharge a patient depends on a number of factors. These include the particular surgery a patient might have undergone and, whether the patient has undergone surgery or not, the patient’s pain needs over the days prior to discharge. There are also a number of patient-specific factors. Pharmacy or pain consult services may be able to provide you with further guidance in more com plex cases. For more details, see the module on Opioid Prescribing at Discharge.
There is no “best” analgesic for all types of pain. Selection of the most appropriate analgesic depends on the kind of pain a patient has. For example, whether the pain is nociceptive (such as incisional or from bowel gas) vs neuropathic pain or chronic pain due to neural plasticity changes. For more details, see the modules on pain management for specific pain syndromes and the modules on chronic pain.
A few principles guide prognostication for how long surgical pain is expected to last. Generally, incisional pain heals first, then musculoskeletal pain, then neuropathic pain. Pain of acute onset (e.g., an acutely herniated disk) usually heals faster than longer-term problems (e.g., chronic lower back pain).
Pain relief after surgery is dependent on the kind of procedure performed. Kyphoplasty and cervical arthroplasty are very different than lumbar fusions –with the latter having a much longer recovery.
Pain in itself increases the risk for a postoperative delirium. Pharmacologic interventions are often necessary to treat pain successfully. This often means opioids will be administered. For an elderly patient, the co-prescription of gabapentin and opioids should be avoided. Importantly, non-opioid pain interventions should also be employed. Non pharmacological interventions such as cognitive behavioral therapy, guided imagery or meditation should also be used.
Pain should be treated as a component of delirium prevention.
For the adult patient with hepatic disease, acetaminophen (APAP) may be judiciously prescribed. 2 grams a day is generally safe, even if the patient has cirrhosis. An inpatient team pharmacist is also able available to provide information on renal- or hepatic-dosing of medications.
The California prescription drug monitoring program (CURES database) provides information on pharmacy filling of prescribed substances for a given patient. Of note, methadone or buprenorphine prescribed from an opiate treatment program (OTP) or from pharmacies embedded in outpatient buprenorphine induction clinics may not show up on CURES.
If you have questions about initiating MOUD on an inpatient at UCSF Health, please consult the OUD MAT advice service via pagerbox. You may also consult social work to help with connecting your patient to outpatient resources.
Clinical Pearl: You do not need to have a X-waiver for your DEA license to prescribe methadone or buprenorphine in the hospital.
Long-acting opioids are reasonable if pain is expected to continue long after the hospital admission, but should not be started for acute pain. Long-acting opioid dose can be calculated by first using short-acting opioids to achieve satisfactory pain control. The OME use from the past 24 hours can then be calculated and divided by two, allowing calculation of the equivalent dose of long-acting opioid as well as adjusting for opioid incomplete cross-tolerance.
Individual UCSF Health ambulatory practices have guidelines for referencing on when and how to taper opioids, screen for substance use disorders, or stop full agonists and switch to partial opioid agonist therapy for opioid use disorder if necessary. For some patients, opioid tapering may be as slow as a 10% per month decrease in opioid dose.
A transdermal buprenorphine patch-assisted protocol may be used to transition patients on high doses of full agonist opioids to buprenorphine. Contact local pain management or internal medicine experts if needed for assistance in this process.
Evidence-based treatments for opioid use disorder, such as XR-naltrexone, methadone, or buprenorphine, should be offered to patients with opioid use disorder.
In the hospital, no special licensing is needed to prescribe methadone or buprenorphine for opioid use disorder. After discharge, methadone for opioid use disorder can only be given at a methadone clinic (opiate treatment program, OTP). After discharge, buprenorphine for OUD requires a provider (MD, NP, PA) have an X waiver for on-going prescriptions.
Opioid withdrawal prevention with methadone or buprenorphine should be offered in the hospital and started regardless of whether the patient is interested in long term medication for OUD (MOUD). Assessment of opioid withdrawal can be achieved via the COWS (clinical opiate withdrawal scale) questionnaire. Buprenorphine or methadone treatment dose is guided by COWS score, as well as society and institutional initiation guidelines.
If methadone or buprenorphine was stopped prior to admission, the timing of treatment is critical. A missed single dose is not critical due to the long half life of both drugs. If MOUD has been discontinued for a longer period we suggest to reach out to the OUD advise service or an inpatient pain service. If appropriate at that point, MOUD can be restarted with careful and slow initiation.
Generally, there are many places in San Francisco where patients can receive free or affordable methadone or buprenorphine. Social work or specialty consult services may assist in this process.
Clinical Pearl: Most patients with OUD who are retained in care and treatment with buprenorphine require doses of 16mg or higher. When patients receive lower doses or do not have their cravings adequately treated, they may return to use.
The main indication for consulting a pain service should be challenging pain control in a patient resulting in consistently high reported pain scores or expressed dissatisfaction with pain management. As a general rule, if a patient reports repeatedly very high pain scores or when pain threatens ambulation goals, a pain service consulted should be considered unless the primary service already employs a provider with extensive experience in pain management.
The question whether high opioid use should trigger an automated pain consult is more controversial. However, since patients with increased opioid use can benefit from opioid sparing interventions that are exclusive to the pain services such as regional anesthesia techniques, as well as intravenous ketamine and lidocaine infusions, consulting a pain service in such a patient is encouraged.
Lastly, patients with an opioid use disorder should be seen by someone experienced in managing this condition such as the OUD Advise Service or a Pain Management Service.
Sometimes there is a bit of a grey area which service might be the most appropriate choice for a given patient, but there are some general rules that guide the scope of work for each service.
- Acute Pain Service: Most “acute pain” is seen in after a surgical procedure. These patients are seen by the Acute Pain Service even if they have a history of chronic pain, including acute pain related to cancer or cancer treatment.
In addition, the Acute Pain Service sees patients with severe or concurrent medical illness resulting in acute pain even when the pain is not triggered by trauma or surgery.
- Chronic Pain Service: This service sees patients with acute on chronic or chronic pain, not related to a surgical procedure. Input may be provided on the appropriateness of interventional techniques for a patient’s condition (e.g., for cancer pain). This service also provides guidance on the inpatient management of devices implanted for chronic pain, such as neurostimulators or intrathecal pumps. This service is also the after-hours point of contact for the UCSF Health Pain Management Center faculty practice.
- Palliative Care: The indication for consulting the Palliative Care service for pain management is when a patient with a life-limiting illness experiences pain that is difficult to control.
The most effective way to reduce opioid use is the aggressive use of multimodal analgesia: the concurrent use of multiple analgesic approaches that have a synergistic effect on pain control while reducing potential side effects. The most important principles of multimodal analgesia are:
· Use local and regional anesthesia techniques whenever possible
· Use scheduled acetaminophen unless contraindicated
· Use anti-inflammatory drugs (NSAIDS) unless contraindicated
· Consider the use of gabapentinoids for a limited time in the treatment of acute pain
· In patients with severe pain, consult a Pain Management Service to allow the use of intravenous ketamine or lidocaine
· Other multimodal analgesics might be appropriate for the patient. Consider consulting a Pain Management Service for initiation of therapies using antidepressants, muscle relaxants, or alpha agonists.
Continue the multimodal analgesic regimen the patient received as an inpatient. If the patient is receiving acetaminophen and NSAIDS, ask the patient to continue taking these medication for another two weeks. If the patient is using a gabapentinoid for acute pain, ask the patient to continue it for up to two weeks or until they stopped taking opioids for acute pain, whatever happens first. The chronic use of gabapentinoids outside the FDA-approved indications is discouraged.
Several surgical services at UCSF developed clear guidelines for opioid prescribing based on the patient’s surgical procedure. For other procedures, non-surgical patients, or opioid tolerant patients, inpatient opioid use prior to discharge use should guide discharge opioid prescription.
Most "nerve blocks" for chronic pain are best suited for the outpatient setting. Whether an inpatient is a candidate for a "nerve block" or pain device depends on many factors, including life expectancy, coagulation status, co-morbid conditions, and more. Similar principals apply to the question of a “pain pump.”
If your patient has an intrathecal pump, please call the chronic pain service and do not let the patient get an MRI until you know more about the device. Getting an MRI without first emptying the contents of certain IT pumps may result in patient death.
Cognitive-Behavioral Therapy (CBT), is a biobehavioral, evidence-based treatment for chronic pain that targets maladaptive coping behaviors, unhealthy cycles of inactivity and avoidance, overreliance on pain medications, and common comorbidities such as anxiety, depression and trauma. It offers patients scientifically-supported tools for pain management such as pacing for pain, sleep hygiene, fatigue management, guided imagery, cognitive restructuring, mindfulness, and emotion regulation.
-CBT has been shown to be more effective than medication alone for improving chronic pain and functioning, has very few risks, and has no side effects. CBT has also been shown to be effective for reducing medication use and can be used to facilitate opioid-tapering.
Yes! The UCSF Pain Management Center and the Osher Center are two outpatient centers able to connect patients to psychological services. These intervention can include Cognitive Behavioral Therapy (CBT), mindfulness, biofeedback, manual therapy, physical therapy, occupational therapy, and other nonpharmacological options.
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