The Problem of Chronic Non-Cancer Pain

by Timothy Gieseke MD, CMD

Since the CDC guidelines for managing pain were published in early of 2016, state medical boards are increasingly scrutinizing physician practices to insure that we are managing acute and chronic pain in a way that minimizes the risk for opioid addiction and drug overdose death.  I have attached the CDC Summary Fact Sheet for these guidelines which unfortunately provides little guidance for the care of chronic non-cancer pain patients who are already on potentially unsafe doses of opioids.  The guidelines discourage a daily MME (morphine mg equivalents) > 50, but many of the patients I receive from the acute hospital for rehab are already on MME > 90- 100, which has an 8 times greater risk of accidental overdose. The CDC has a nice handout for Calculating Total Daily Dose of Opioids for safer opioid prescribing.  The CDC has a free new mobile app for android and apple phones called “CDC Opioid Guideline” which has a calculator within it.

Chronic non-cancer pain is complex and assessments are challenging.  I commonly receive patients labeled as having chronic pain by the acute hospital with very little history about the history of their chronic pain or of other associated conditions that may contribute to their experience of pain like drug misuse, mental health, or adjustment disorders.  These conditions commonly coexist in persons with chronic pain and magnify the patient’s pain experience. Many of these rehab admissions also have an acute pain problem superimposed on their chronic pain problem. This commonly results in persistent pain intensity score of 10 in the facility putting nurses and facility at risk for allegations of inadequate pain care, while putting pressure on prescribers to prescribe more opioids than they believe are appropriate and safe.  In addition, patients and nurses often have unrealistic expectations for the degree of pain control achievable with only analgesic medications.

I recently received a call from a worried nurse in a patient on chronic opioids > 50 MME who was 1 month post op and within days of discharging home.  She was participating in rehab, social activities, and had regained weight and ADLs. From my perspective, her pain could not be a 10, since persons with that much pain usually aren’t out of bed and have trouble eating, socializing, and performing ADLs.  I asked this nurse to google the PEG tool (see attachment) recommended by the CDC for assessing pain control the prior week, which better measures the other important domains of pain management.  On this scoring system, the patient was actually a 7 which is more consistent with my assessment earlier that week and was a realistic target for a safe discharge home.

Because acute pain is commonly superimposed on chronic pain, nurses need to be more precise in their assessment of these changes of condition.  The PQRST tool (see attachment) along with a pertinent physical exam improves the SBAR for communicating with providers and helps providers develop more effective and timely interventions.   

Because mental health, drug misuse, and adjustment disorders are so prominent in pain disorders, broadening your care team to include clinical psychologist, psychiatrists, and pain specialists can be extremely helpful.  

For a wealth of other resources for pain care designed for the SNF setting, please visit:


CDC Chronic Pain Guidelines Factsheet

PEG Pain Screening Tool

Assessment of Pain: Questions to Consider during Assessment of Pain (PQRST):