September 14th, 2015

Universal Precautions In Pain Medicine: A Rational Approach To The Treatment Of Chronic Pain

Editor’s Note: Dr. Howard A. Heit has been my primary guide for working in the clinical area where pain and addiction overlap. Most patients taking opioid pain medicine do not become addicted, but many are concerned about this possibility, as are the physicians who treat them. Those patients who do become addicted are among the unhappiest people that I have met. They are very much in need of the type of compassion and expertise that Dr. Heit brings to our field.

By Dr. Howard A. Heit 

“Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain,” initially published in 2005, presented a 10-step approach to the assessment and management of patients suffering from chronic pain.*

Over the past decade, Universal Precautions has become a template for the treatment of chronic pain with controlled substances like pain medicine. It has been referenced in peer review journals, textbooks, and government regulatory policies. Its principle is that treatment should be based upon mutual trust and respect between patient and practitioner, both of whom should be committed to setting and achieving realistic goals in both cancer and non-cancer pain management.

The term “Universal Precautions” originated in the Occupational Safety and Health Act (OSHA) of 1970, which provided information and regulations to develop workplace health and safety standards.  This law established regulations that successfully assisted the healthcare professional in combating the spread of infections, such as HIV and AIDS.

Using this concept, Universal Precautions presented a careful 10-point plan for the medical professional’s assessment of all persistent pain patients within the biopsychosocial model with appropriate “boundary setting” before writing the first prescription. By using this approach, the authors hoped that both pain patient stigma and the overall risk of pain management could be reduced while patient care improved.

The following “Ten Principles of Universal Precautions” may be applied to the treatment of many chronic diseases:

  1. Diagnosis with appropriate differential
  2. Psychological assessment including risk of addictive disorders
  3. Informed consent (verbal vs. written/signed)
  4. Treatment agreement (verbal vs. written/signed)
  5. Pre/post intervention assessment of pain level and function
  6. Appropriate trial of opioid therapy +/- adjunctive medication
  7. Reassessment of pain score and level of function
  8. Regular assessment of the “Four As” of pain medicine: Analgesia, Activity, Adverse reactions, & Aberrant behavior
  9. Periodic review of pain diagnosis and comorbid conditions, including addictive disorders
  10. Documentation, if you do not document your encounters with the patient in the medical-legal record — it is a figment of your imagination!

Pain management, including pain medicine, should be defensible, rational and compassionate. As Dr. Francis Peabody advised students at the Harvard Medical School on October 21, 1926, “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

Howard A. Heit, MD, FACP, FASAM is board certified in internal medicine and gastroenterology/hepatology. He is a diplomate in addiction medicine and is certified as a medical review officer and chronic pain specialist. He also serves as an assistant clinical professor at Georgetown University.

*Gourlay, D., Heit, H.A., and Almahrezi, A. Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain. Pain Medicine. 2005; 6(2):107-12.

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