Below is a list of learning resources and clinical tools that we’ve assembled to supplement the NEJM Knowledge+ Pain Management and Opioids CME/CE activity. These resources are intended to address the topics that clinicians find most challenging in pain management, such as facilitating behavior change with patients and determining the best strategies for tapering opioid therapy.*
Managing Specific Types of Pain
- Diagnosis & Treatment of Low Back Pain: An algorithm from NEJM Knowledge+ that describes how to diagnose and treat low back pain, including simple back pain, radiculopathy, and stenosis
- Diagnosis & Treatment of Fibromyalgia: An algorithm from NEJM Knowledge+ detailing the diagnosis, evaluation, and treatment of fibromyalgia
- Diagnosis & Treatment of Neuropathic Pain: An algorithm from NEJM Knowledge+ that describes how to diagnose and treat neuropathic pain, including painful peripheral neuropathy and postherpetic neuralgia.
- Diagnosis & Treatment of Osteoarthritis: An algorithm from NEJM Knowledge+ detailing the diagnosis, evaluation, and treatment of osteoarthritis.
- Common Interventional Pain Procedures: An illustrated guide from NEJM Knowledge+ of 16 of the most common interventional pain procedures (considered only after failure to achieve pain relief with adequate trials of medication, at least 6 weeks of physical therapy, or both). This PDF includes illustrations, lists of indications, clinical pearls, potential complications, and brief instructions on how to perform the procedures.
- The Role of the Pain Psychologist in Managing Chronic Pain: An infographic from NEJM Knowledge+ on the biopsychosocial model of pain, referring a patient to a pain psychologist, the pain psychology assessment, and common pain psychology interventions
Evidence on Opioid Therapy in Chronic Pain
- Opioid Efficacy for Chronic Pain: A slide from Boston University School of Medicine that summarizes available evidence on the use of opioids for chronic pain
Monitoring Patients on Opioid Therapy
- Minimum Level of Monitoring Based on Risk: A chart from Boston University School of Medicine that shows how frequently urine drug testing, pill counts, and other monitoring tools should be used to assess opioid safety
- Urine Drug Testing in Chronic Opioid Therapy — Clinical Considerations & Common Laboratory Methodologies: These two linked infographics provide information on how to conduct urine drug testing — the first deals with clinical considerations and what to say to the patient in case of concerning findings, and the second explores the laboratory methodologies involved and how to interpret results.
- Sample workflows for executing a multidisciplinary/interprofessional approach to new and established chronic-pain patients (slides from SCOPE of Pain)
- Rotating Opioids to Manage Chronic Pain: An infographic from NEJM Knowledge+ that describes why opioid rotations work, when to consider opioid rotation, what to consider when selecting a new drug and the dose of the new drug, how to counsel patients during a rotation, and the steps involved in one rotation method.
- Opioid Taper Decision Tool: A 3-page guide from the U.S. Department of Veterans Affairs that outlines sample plans for tapering opioids and describes treatments for specific withdrawal symptoms
- BRAVO! A Collaborative Approach to Opioid Tapering: A 15-page document from Oregon Pain Guidance and Dr. Anna Lembke that outlines a safe and compassionate strategy for approaching opioid tapering with patients
- BRAVO Overview: A one-page overview of the BRAVO approach to opioid tapering
- When and How to Taper Opioids: Adapted from BRAVO, the following table and two-part short, animated video series for primary care clinicians describes common reasons to taper and shows how to taper a patient’s opioid prescription.
- Table: When to Consider Opioid Tapering
- When to Taper Opioids (Video):
- How to Taper Opioids (Video):
Navigating Difficult Conversations
- Words That Work: An infographic from Opioid Life Saver Training that provides suggested wording to use when talking with patients about their opioid use
- Challenges of Managing Chronic Pain with Opioids – Part 1: A 23-minute episode of the NEJM Resident 360 Curbside Consults podcast in which experts examine a series of case scenarios about worrisome opioid use and discuss how clinicians can handle their feelings during these difficult patient visits
- Challenges of Managing Chronic Pain with Opioids – Part 2: A 21-minute episode of the NEJM Resident 360 Curbside Consults podcast in which a patient receiving opioid therapy for chronic pain discusses how he manages his relationship with his clinician, his pharmacy, and society at large
- Motivational Interviewing: Inspiring Patients to Change: An infographic and four-part video series introducing the principles of motivational interviewing to help clinicians increase the chances of a successful discussion with patients.
- Infographic: Motivational Interviewing: Inspiring Patients to Change
- Motivational Interviewing, Part 1: Engaging (Video)
- Motivational Interviewing, Part 2: Focusing (Video)
- Motivational Interviewing, Part 3: Evoking (Video)
- Motivational Interviewing, Part 4: Planning (Video)
- Frequently Asked Questions about Prescribing Naloxone: A list of 15 questions clinicians commonly ask about naloxone, answered by experts from Prescribe to Prevent
Understanding and Recognizing Opioid Use Disorder
- Stages of the Addiction Cycle: An infographic from the New England Journal of Medicine that details the neurobiology of addiction
- DSM-5 OUD Criteria: A complete list of the diagnostic criteria for opioid use disorder
Managing Opioid Use Disorder (OUD)
- Managing Opioid Use Disorder for the Generalist: A 60-minute episode of The Curbsiders Internal Medicine podcast that reviews the art of building a therapeutic relationship with people who have substance use disorders, the differences between the three FDA-approved medications for OUD, and the nitty-gritty of prescribing buprenorphine for OUD
- Medications to Treat Opioid Use Disorder (OUD): A chart from NEJM Knowledge+ comparing methadone, buprenorphine, and naltrexone for the treatment of OUD
- Initiating Buprenorphine: An infographic from The Curbsiders Internal Medicine that describes the four key steps to starting buprenorphine for OUD treatment
- Buprenorphine for Pain Management & Treatment of Opioid Use Disorder (OUD): An infographic from NEJM Knowledge+ that compares the various uses of buprenorphine
- PCSS Mentoring Program: A mentoring program where clinicians can: (1) post questions in an online discussion forum moderated by addiction specialists and receive answers from clinical experts and other colleagues; (2) ask clinical questions related to substance use disorder and receive a prompt response via email; and (3) match up with a mentor in their region who will discuss specific clinical issues with them and provide individualized, one-on-one guidance in person or via email or phone
Tools for Clinical Practice
- Brief Pain Inventory: A 15-item questionnaire to assess the intensity of a patient’s pain and the extent to which it is interfering in the patient’s daily activities
- PEG assessment tool: A 3-item questionnaire derived from the Brief Pain Inventory
- Roland Morris Disability Questionnaire: A 24-item questionnaire to assess low back pain specifically
- STaRT Back Screening Tool: A 9-item questionnaire to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision-making
Assessing Depression and Anxiety
- Patient Health Questionnaire (PHQ)-2: A 2-item questionnaire to screen for depression; to be followed by the PHQ-9 if positive.
- Generalized Anxiety Disorder (GAD)-2: A 2-item questionnaire to screen for anxiety
Screening for Risk of Opioid Misuse
Assessing Risk of Opioid Overdose
- Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD): A questionnaire used to estimate the risk of overdose in opioid-treated patients
- Risk Classes and Predicted Probability of Serious Opioid-Induced Respiratory Depression during the Next 6 Months: A guide to interpreting the RIOSORD score
Counseling Patients About Opioid Therapy
- Prescription Opioids: What You Need to Know: A 2-page document (from the U.S. Centers for Disease Control and Prevention) for patients that lists the risks and adverse effects of opioids as well as safety-related steps that patients can take
- How to Use the VA Auto-Injector Naloxone Kit or Naloxone Nasal Spray: Two 7-minute videos (from the Veterans Health Administration) for teaching patients how to use the different formulations of naloxone in case of overdose
- Drug Disposal: Drug Take-Back Locations: A resource from the U.S. Food and Drug Administration that allows you to find drop-off locations near you via a searchable database or Google maps — and that also provides information on periodic take-back events
Sample Patient–Provider Agreements from:
Assessing Symptoms of Opioid Withdrawal
- Clinical Opiate Withdrawal Scale (COWS): An 11-item scale scoring the frequency and severity of withdrawal symptoms
Locating OUD Treatment Centers and Authorized Buprenorphine Prescribers
- SAMHSA Treatment Locator: A search tool (from the Substance Abuse and Mental Health Services Administration) to locate (a) treatment facilities for substance use disorder and (b) practitioners authorized to prescribe buprenorphine for OUD
MME Charts and Calculators
- Calculating Total Daily Dose of Opioids for Safer Dosage (U.S. Centers for Disease Control and Prevention)
- Opioid Conversion Calculator (Oregon Pain Guidance)
- Opioid Conversion Calculator Morphine Equivalents — Advanced (Global RPh)
Drug Databases and Reporting Forms
- DailyMed: Searchable database (from the National Library of Medicine) of label information for drugs marketed in the United States
- CredibleMeds: Searchable database of drugs that prolong the QT interval and induce torsades de pointes
- MedWatch Online Voluntary Reporting Form: A portal to report all suspected overdoses from prescribed medications, including opioids, to the U.S. Food and Drug Administration
*The information included here is provided for educational purposes only. It is not intended as a sole source on the subject matter or as a substitute for the professional judgment of qualified health care professionals. Users are advised, whenever possible, to confirm the information through additional sources.