Pain management for the dermatologist

Pain is a commonly presented symptom to dermatologists, both in the acute and chronic settings. How to choose the appropriate pain management path was the topic of Friday’s session “Pain Management for the Dermatologist” (F013).

In acute presentations, such as surgery, dermatologists need to understand and observe proper preoperative, operative, and postoperative assessment and treatment protocols. “As a dermatologic surgeon, we are entirely responsible for pain control,” said session speaker Bryan Carroll, MD, PhD. “Our goal should be complete alleviation of pain and maximizing patient comfort.”

In chronic presentations, it is important for dermatologists to recognize conditions that are often painful or unbearable. Examples include ailments such as hidradenitis suppurativa, pyoderma gangrenosum, and vasculitis/vasculopathy of the skin. As experts of these conditions, dermatologists should be responsible for comprehensive treatment. Deferring to a family physician or pain specialist, if not needed, can be wasteful, burdensome, and imprudent. “My basic philosophy,” said speaker Robert Micheletti, MD, “is that if we are treating patients with these conditions, we should be willing to treat the pain that goes with them, at least within our scope of practice.”

Below is a high-level guide to general pain management, including when to administer non-opiates versus opiates. The speakers also provided tips to identify opiate-seeking behavior and improve the pain management process for both physicians and patients.

How to improve pain management:

  • Set expectations upfront. This includes expectations of symptoms, treatment, and side effects. Be able to characterize and explain the pain that corresponds with serious medical conditions. Differentiate whether a patient’s pain is acute or chronic. Understand what is reasonable or appropriate (a clinical key indicator), and what is out of the ordinary. Let patients know that pain medications are a temporary solution for a specific purpose, which is to treat a surgery or condition. Prescriptions do not include refills, doses should decrease over time, and long-term use is not recommended. Be transparent about possible side effects. If a patient has history of chronic pain, mental conditions, or addiction, assess the risks of prescribing an opiate that could be habit-forming.
  • Establish an informative pain contract model. This is a structured way to provide patient education and get them to agree to pain medicine guidelines. It also prevents physicians from getting into challenging or awkward situations.
  • Stay within your comfort zone. Do not attempt to treat pain that is outside your realm of expertise or scope of practice. Instead, refer the patient to a pain specialist. Be upfront with patients so that they understand your medical responsibility.

How to identify opiate-seeking behavior: 

  • Patient complains of pain that does not correspond with active symptoms, conditions, or surgery.
  • Patient asks for frequent refills.
  • Patient reports losing prescriptions.
  • Patient avoids you, the physician, and tries to coerce staff.
  • Patient is demanding or exhibits unreasonable behavior.
  • Patient has a history of opiate prescriptions, particularly from more than one provider. Some states have opioid registries, where providers are required to report the patient and prescription details.


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