Like many pain clinics, we sometimes prescribe opioids as part of an overall patient treatment plan. While opioids sometimes play a role in managing chronic pain, we strive to find safer and more effective pain management alternatives for our patients.Nura is a multidisciplinary interventional pain clinic- this means that if we prescribe opioid medication, we also require you to participate in physical therapy, behavioral health services and interventions like injections/nerve blocks/etc. We are here to provide alternatives to high-dose opioids. If you are only interested in opioid medication management and nothing else, Nura is probably not the clinic for you.Nura provides medication management to help manage and reduce pain. We take into account the intensity and duration of pain, along with other factors such as age, other medical challenges, and other medications being taken. We may prescribe one or more medications as part of a comprehensive pain management plan.For these patients, we offer specialized therapy programs tailored to long-term opioid users. The programs are structured to reduce dependence on narcotic pain medications and minimize healthcare visits by promoting effective self-management.COMP Chronic Opioid Management ProgramAt Nura, we will undertake a thorough medical history, perform a complete physical examination, and make recommendations for treatment.Nura providers may or may not agree to prescribe opioids to the patient during the first visit. If we choose to continue prescribing the patients opioid medications, we may do so on a limited basis for a defined time period while we attempt to precisely diagnose and treat their pain with therapeutic injections, nerve ablation techniques and implantable pain control options coordinated with physical therapy and psychology treatments as appropriate.The chronic opioid pain management program provides a set structure for long-term opioid prescribing which includes:Formal, signed Opioid AgreementMonthly medical evaluations at which time prescriptions are dispensedParticipation in prescribed physical therapyParticipation in prescribed psychology evaluations and treatmentsRandom urine drug testing at least twice per yearCOMPASS: An Ongoing Structure for SuccessNuras Compass program is designed to support long-term patients who use opioids to manage pain, and who may have a history of abuse or difficulty adhering to expectations.  In addition to the features of COMP, this highly-structured program also involves monthly, same-day appointments with the caregiver team:Medical care delivered by a CNP or PA-CBehavioral assessment and treatment by a licensed mental health professionalPhysical assessment and treatment delivered by a licensed Physical TherapistChronic Pain ProgramNuras comprehensive four-week Chronic Pain Program offers patients an empowering environment for learning pain management strategies and coping skills. Better yet, you will work alongside fellow patients under the compassionate guidance of expert staff. Learn how the Chronic Pain Program can help you get back into life!  Contact us for help at 763-537-6000 or visit www.nuraclinics.com

Chronic pain is a major health issue affecting millions of people globally. It can have a debilitating impact on lives, preventing people from enjoying activities they love and limiting the quality of their day-today life. Recent surveys indicate that approximately 50 million adults in the U.S.more than one in fivereport experiencing pain every day or most days, most commonly in their back, hips, knees, or feet. People with chronic pain say it limits their functioning, including social activities and activities of daily living.   Chronic pain is generally defined as pain persisting for longer than 12 weeks despite medication or treatment.  Clinicians may use various determinations, but a general rule of thumb is that the pain has lasted beyond the expected duration after an acute injury or illness or is present without any history of an injury or insult. Taking a Multimodal Approach to Treatment Treating chronic pain is not a one-size-fits-all endeavor. To optimize outcomes, it is critical to form a multimodal treatment strategy. A multidisciplinary approach has been shown to be one of the most effective ways to manage chronic pain. A combination of medications, physical and behavioral therapies, injections, neuromodulation and in rare cases, implantable pain pumps should be considered in order to provide patients with the best possible results. Physicians who specialize in interventional pain management typically offer a full range of such options and work with their patients to develop a course of treatment aimed at helping them manage their chronic pain to the best extent possible.Classifying PainFor all physicians considering the challenge of chronic pain management, it may be helpful to review the different types of pain classification: Somatic pain is felt in the muscles, bones or soft tissues. It is typically localized and can be intermittent or constant. It is often described as anaching, gnawing, throbbing, or cramping type of pain. Visceral pain comes from the internal organs and blood vessels and is typically more diffuse than localized. Visceral pain tends to be referred to other locations, and can be accompanied by symptoms such as nausea, vomiting, or tension in lower back muscles. It can be intermittent or constant, and is typically described as being dull, squeezing, or aching. Neuropathic pain occurs when the nervous system is damaged or not working properly. It can be experienced at the various levels of the nervous The Importance of Multimodal Therapy Tools for treating chronic pain system, from the peripheral nerves to the spinal cord and the brain. Nerve pain can be described as shooting, sharp, stabbing, lancinating, or burning.Tools in the Pain Management ToolboxA multimodal approach to managing chronic pain often involves layering options that range from conservative to highly interventional. Conservative management-The least invasive options for many patients include first-line therapies such as topical analgesics, physical therapy, acupuncture, chiropractic, transcutaneous electrical nerve stimulation (TENS) therapy and massage therapy. For some patients experiencing mild or temporary pain states, these interventions can be enough to manage the problem. For individuals who experience ongoing pain, these interventions can be helpful adjunctive therapies alongside other more intensive approaches.Medication management- Depending on the type of pain and its severity, doctors may opt for either short- or long term use of over-the-counter medications like nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, anticonvulsants, neuropathic agents and in severe cases, opioids. While these medications can provide short-term relief, they may not be sufficient to manage chronic pain.  Regarding the use of narcotic pain relievers (such as fentanyl, buprenorphine, oxycodone, hydrocodone, hydromorphone, morphine and methadone), and practitioner education in the last few years has been extensive.  Education has reduced the number of opioid prescriptions and underscored their use as a tool for management of acute pain, which is their primary indication. There is considerable research showing that the use of opioids for chronic pain does not provide substantial benefit beyond the acute care period. Most providers are increasingly aware of this, and educating their patients about opioid risks and benefits is an ongoing responsibility of all physicians.  There are several non-narcotic prescriptions which can be used to manage chronic pain. The group of gabapentinoids (gabapentin and pregabalin) can be particularly effective, especially for neuropathic pain. Another commonly used medication is duloxetine, a serotonin and norepinephrine reuptake inhibitor, often used for neuropathic pain in combination with gabapentin. For myofascial pain, muscle relaxers such as tizanidine, baclofen, and cyclobenzaprine can be helpful for certain patients.  Medical cannabis is increasingly understood to be useful for select patients, with about a 5060% reported success rate in reducing pain. Anecdotally, people who have previously used marijuana recreationally seem to respond well to it in a pain management context, because they understand what having cannabis in their system feels like. Other patients who have not used cannabis previously may not care for the side effects and therefore not report such positive results. In general, though, many physicians and patients agree that cannabis can be helpful to try in low doses and safely ingested in oral form. A comprehensive, multidisciplinary pain practice typically has physicians who can certify patients for medical cannabis.Interventional TherapiesThere are several interventional procedures that can be effective in addressing chronic pain, starting with local injections in the joint, spine or nerves. These can be trialed as part of a treatment plan for certain types of chronic pain, particularly in cases where the specific sources of pain have been identified. For example, injections can treat arthritis, nerve blocks can relieve neuropathic pain and epidural steroid injections can assuage radicular back and neck pain. When combined with physical therapy, these targeted treatments may help reduce inflammation and improve mobility. In cases where injection therapy does not prove adequate for ongoing pain relief, other advanced interventional  50 million adults in the U.S. more than one in five report experiencing pain every day or most days.  Therapies may be utilized. The technology and practice of implantable pain control devices is advancing rapidly, with life-changing outcomes for many more patients than ever before. These devices deliver very low doses of specifically targeted pain relief around the clock and present less risk of addiction and fewer side effects, removing concerns around either forgetting to take or taking too much medication. Peripheral nerve stimulation (PNS) therapy delivers an ongoing series of electrical pulses to a targeted area of a peripheral nerve, reducing the pain signals that are sent from the body to the brain.  For other cases, spinal cord stimulation (SCS) can be an effective solution. SCS therapy also uses electricity to modulate the way pain signals are sent from the body to the brain, with the modulation being done at the level of the spinal cord. One of the most common indications for SCS is failed back syndrome: people who have had surgery on their back but continue to have low back pain and possibly leg pain. SCS therapy can also be used for other indications, such as painful neuropathies including diabetic neuropathy and alcohol-induced neuropathy, as well as complex regional pain syndrome involving chronic arm or leg pain that develops after injury or illness. The data supporting use of spinal cord stimulation for chronic pain is favorable. The technology of today has greatly improved compared to even five or ten years ago, and results are getting better. Neuromodulation does not work for every patient, however, and we dont ever promise or expect 100% pain relief; the goal is typically a 5075% reduction in pain, enough to improve comfort, mobility and quality of life. In some cases where systemic medications, surgeries, interventional procedures and neuro-stimulation implants have failed, pain specialists may recommend an intrathecal drug delivery system, also known as a pain pump. The pain pump is surgically implanted in the abdomen or upper buttock and delivers a steady supply of medications directly into the intrathecal space where the spinal cord is located. The medicationstypically a combination of an opioid and a local anestheticcan be provided in very low doses, directly at the site of where those medications work on the spinal cord. Intrathecal drug delivery is sometimes referred to as a targeted drug delivery because it primarily targets spinal binding sites for pain relief, bypassing the blood brain barrier by infusing the therapeutic agents into the cerebrospinal fluid. Because of the targeted delivery, it reduces the mental side effects associated with systemic opioid management. Intrathecal drug delivery has flourished since its inception because it is uniquely effective. Many experienced pain physicians consider it to be the best therapy for the worst pain.Physical and Behavioral TherapyIn conjunction with other interventions, it is paramount for pain management physicians to utilize physical and behavioral therapy as part of the treatment plan for chronic pain patients when indicated. Physical therapists can teach patients exercises that focus on posture, mobility, balance and strength-building that can provide long-term relief from chronic conditions like arthritis, fibromyalgia and low back pain. Behavioral therapy can also help patients address underlying mental health issues that commonly go hand in hand with chronic pain. When patients have depression or anxiety that is not well controlled, their chronic pain is often quite challenging to treat effectively.Referring to a Pain SpecialistGaining control over a patients chronic pain can present a real challenge to primary care physicians and other general practitioners. Faced with a patient that proves refractory to usual treatments, doctors may consider referring the patient to a specialist in pain management. Primary care clinicians should be aware of their options for referring a patient suffering from chronic pain in order to provide them with the best hope for achieving long-term relief. An experienced specialist may be able to tailor treatments specifically targeted for their patients condition, which can be invaluable when handling complex cases such as chronic pain conditions.  Chronic pain is challenging to treat.  As opposed to acute pain, wherein physicians often know the etiology of a patients pain, chronic pain often requires a more extensive workup to identify the source or sources of a patients painful condition. This can be especially true when it comes to spinally mediated pain, which is the most common complaint chronic pain physicians encounter.  The spine is a complex anatomic structure. The task a pain specialist undertakes is to find out what may be causing the pain, utilizing advanced imaging, tests and interventional therapies, which are often diagnostic as well as therapeutic.  When a patient is initially seen by a pain specialist, the physician takes a full history, reviews the referring providers notes and any diagnostic results to date. As previously mentioned, physical therapy is often a first line intervention for patients. If psycho-social stressors are present, behavioral health consultation is warranted. Additional workup such as diagnostic tests and imaging will then be considered if indicated. Once this workup has been initiated, the pain physician can hopefully find the source of the chronic pain and begin interventions and allied therapies in a more targeted approach. This all happens concurrently with the patient working with physical therapy, seeing a behavioral health therapist, and optimizing a medication regimen along the way as indicated. A comprehensive pain clinic often has physical therapy and behavioral health specialists on site as a part of their practice and can offer a multidisciplinary approach to chronic pain under one roof. A Focused, Intensive ApproachMany pain specialty practices offer a chronic pain program an intensive, focused initiative designed for patients who may have exhausted their therapeutic options, are no longer seeking a specific diagnosis or additional interventions, and are simply living with chronic pain they are likely to have for the rest of their lives. Our program, and programs like it around the country, combine education with physical and behavioral therapy. Patients learn principles for self-management: quality nutrition, good sleep hygiene, smoking cessation, benefits of exercise in improving mental and physical healthbasically how all the components of their own behaviors are going to help them manage their pain better and improve their quality of life. These programs are usually quite intensive, with patients coming every day or several days a week for the duration of the program, which may be four to eight weeks in length. Educating Patients and Setting Expectations When we think of patients achieving relief from their chronic pain, we typically mean their pain has become minimal enough that it doesnt unduly affect their daily life. Chronic pain is challenging to treat; the longer the body experiences a hyper-excitable state while in pain, the more the brain remodels and adapts to the chronic pain state. This phenomenon is known as central sensitization and can present as a vicious cycle which can be hard to break. Breaking this cycle is what a pain specialists care team works toward. A key part of chronic pain management is educating patients about their health and their options, making sure they understand time to therapeutic effects, setting realistic expectations for each modality and helping them play a positive role in their pain relief journey.Today more than ever before, there are options that can help nearly every patient. Taking a multimodal, multidisciplinary approach gives us the greatest chance of achieving significant pain management and improved quality of life.Cody Foster, MD, practices at Nura Pain Management and is board certified in Anesthesiology and Pain Medicine

Back pain can have many causes, and many times, back pain will resolve itself in two to four weeks with rest, ice and heat. In fact, 80 percent of Americans will experience back pain at some point in their lives, making back pain one of the most common reasons people visit back pain clinics or miss work.  Back pain that lasts longer than a few weeks is not normal.Causes of Back PainMuscle Strains-Did you know that muscle-related pain is one of the most common reasons for overall back pain? It is true. Muscle related pain can be caused by improper lifting techniques, overuse, poor posture or a sudden awkward movement or fall.Spinal or Disc Problems-Bulging or Herniated Discs: Spinal discs are soft cushions between vertebra. Sometimes, the soft jelly-like substance inside the disc can bulge out of place or rupture, putting pressure on the surrounding nerves causing back pain. Disc related back pain can be caused by an injury. Interestingly, some people who have bulging or herniated discs will never experience any back pain.Sciatica-Sciatica refers to pain that stems from the sciatic nerve, a large nerve extending from the lower back down the back of each leg. Sciatica is not a disorder, but a symptom of another underlying problem, such as spinal stenosis, a pinched/irritated nerve in the lower back or a herniated disc.Other Painful Conditions-If you have spinal stenosis, degenerative disc disease, scoliosis, compression fractures, arthritis or osteoporosis you may also experience pain in the back. These back pain conditions can be treated with conservative, minimally invasiveRisk Factors for Back Pain-There are a few factors that can increase your risk of developing back pain, such as: smoking, obesity, age, physical labor, sedentary work and depression.Diagnostic Testing-To help determine the cause of your back pain, there are several diagnostic tests that can be performed by a back pain doctor or back pain specialist. These may include Xrays, MRI, CT Scan and an Electromyography (EMG). An X-ray shows the alignment of the bones in your spine and whether you have any broken or arthritic bones that may be causing back pain. MRI and CT Scan tests show images of bone, muscle, tissue, nerves, blood vessels, tendons and ligaments. These tests can show disc herniation, muscle tears, ligament problems and can help your clinic doctor or back pain specialist understand your back pain. Electromyography (EMG) is a test used to study nerve and muscle function.Back Pain Treatment Options-At Nura, our clinic doctors and back pain specialists value the importance of an interdisciplinary approach. There are a number of treatment options that help reduce back pain, which include:Physical TherapyEpidural Steroid InjectionDiscographyFacet Joint InjectionTrigger Point InjectionRadiofrequency AblationSacroiliac Joint InjectionIntracept Proceduremild Procedure (Minimally Invasive Lumbar Decompression)Minuteman Procedure (Minimally Invasive Spinal Fusion)Preparing for Your Doctor Appointment-Before your back pain appointment with your clinic doctor or back pain clinic specialist, take note of some important facts.Is your back pain the result of an injury?What movements increase or decrease your back pain?What are the symptoms you have been feeling?How long have you had this back pain?What does your back pain feel like? Dull, aching, stabbing or shooting?What type of work do you do?What treatments or medications have you already tried to resolve your back pain?Call Nura Pain Clinics for further information at 763-537-6000 or visit www.nuraclinics.com

Pain symptoms experienced by those with cancer pain vary from person to person and can range from mild to severe chronic pain. Nura offers several treatment options to manage cancer pain and we coordinate with your oncologist to ensure you have the best care.Causes of Cancer PainCancer may cause pain by applying pressure to or destroying biological structures such as nerves, organs and bones. Cancer can spread from its original site (primary tumor) and travel to other parts of the body (metastasis), causing injury and pain at these sites as well.Pain may also result from cancer treatments like chemotherapy and radiation, which can damage nerves and cause nerve pain in the arms and legs. Patients recovering from cancer surgery frequently experience acute postoperative pain as surgical wounds heal. Aggressive surgery may cause more painful damage; this pain may resolve with healing or it may become chronic.Common pain problems associated with cancer and cancer treatment:Peripheral neuropathy numbness and painful sensations in the feet, legs, fingers, hands and arms from chemotherapyPost-radiation nerve painNerve pain from spinal metastasisBone and joint painSpinal pain from vertebral fracturesAbdominal and pelvic pain from abdominal cancersPersistent pain after cancer surgeryIf you are experiencing pain from cancer or cancer treatments, please call Nura today and our team of top pain specialists will develop a pain management solution specifically for your needs.Treating Cancer PainAlthough cancer-related pain cannot always be relieved completely, a comprehensive plan can reduce pain for nearly all people with cancer, relieving symptoms and improving quality of life.In many cases, cancer pain can be adequately treated with standard pain medications, which may include opioids. However, side effects including nausea, fatigue, mental fogginess and the inability to think clearly may limit the effectiveness of pain medication in some patients.At Nura, we diagnose and treat the physical side of cancer pain with a thorough evaluation and precise, minimally invasive procedures. If pain persists despite treatment, we utilize advanced neuromodulation techniques including trials and implants of neurostimulation systems and targeted drug delivery pain pumps for the most severe pain. These pain control options may serve as alternatives to higher doses of pain medications.Cancer Pain Treatment Options:Peripheral Nerve BlockCeliac Plexus Nerve BlockLumbar Sympathetic Nerve BlockHypogastric Plexus Nerve BlockNeurostimulation systems to treat nerve painPain Pump for Targeted Spinal Drug DeliveryIn addition, if you experience emotional suffering due to cancer, we have specialized psychologists on staff to help with the emotional toll that a cancer diagnosis can take.Our experience has shown that most cancer pain can be managed with conservative treatment, but when pain persists, the most advanced treatment options are available within our clinic. As a national center of excellence for implantable pain control, Nura is ready to help with even the most severe cancer pain.To schedule an appointment, call 763-537-6000. We will coordinate with your oncologist to ensure you have the best care. Or your oncologist can also refer you directly to Nura Pain Clinics.

Treating patients with chronic pain is often complicated and labor intensive. Managing chronic pain with long-term opioids is a controversial practice as the U.S. is experiencing an epidemic of opioid-induced morbidity and mortality. According to recent Centers for Disease Control and Prevention (CDC) data, the overdose death rate from prescription opioids more than tripled from 1990 to 2013 and opioid overdose is now the leading cause of injury death in the U.S. Doctors who prescribe long-term opioids to treat chronic pain are increasingly being held liable for patient overdoses, patient traffic accidents, and drug-related patient injuries. As a physician prescribing opioids, you could be sued for causing addiction, wrongful death, and patient injury; you could be investigated by the medical board and lose your medical license; you could even be prosecuted for murder. Reimbursement for managing opioids is low and does not adequately compensate the physician for the time, effort, and liability risks involved. Why prescribe opioids? Why should any sane primary care physician manage opioids in chronic pain patients? The following reasons come to mind: As physicians, we want to help our patients. Uncontrolled pain can have harmful physical effects such as elevated blood pressure and elevation of stress hormone levels. Chronic pain can imprison the patient in a sedentary lifestyle and lead to suicide from chronic anxiety and depression. Opioids allow some patients to get out of bed and lead a more normal life. Opioids, even at high dose, do not harm the bodys organs, unlike NSAIDs and acetaminophen, which, according to the American Journal of Gastroenterology, cause thousands of American deaths each year from bleeding or liver damage respectively. Some chronic pain patients achieve excellent pain relief, better physical functioning, and life-changing improvement with minimal side effects on long-term opioids and never become addicted. Opioids have been the standard of care for pain management for over 100 years. If you weigh the pros and cons and make an informed decision to manage your chronic pain patients, with or without opioids, a pain management plan will help to keep your patients safe and you out of trouble. The importance of a plan A pain management plan is important in part because it lends structure and thoughtful logic to the management of a complex, controversial, and high-risk disease state. According to the Institute of Medicine, 100 million Americans suffer from chronic pain and one quarter of them have pain that is severe enough to reduce their quality of life. Recent NIH data suggests that 9.4 million Americans take opioids for long-term pain management and approximately 2.1 million may be considered addicted. There is little scientific evidence to prove that opioids are effective after six months of continuous use. In 2014, the American Academy of Neurology concluded that the risks of long-term opioid treatment for headaches and chronic low back pain likely outweigh the benefits. In 2015, an NIH Panel on Opioids concluded, There is insufficient evidence for every clinical decision that a provider needs to make regarding use of opioids for chronic pain. Nonetheless, most experienced physicians agree that a substantial number of chronic pain patients benefit from long-term opioids and use them responsibly. A comprehensive pain management plan will facilitate safe opioid prescribing, help legitimate patients achieve pain relief, and reduce abuse and diversion of prescription opioids. The plan should consider the following. 1.  Identify and document the pain diagnosis you are treating. Chronic radiculopathy, complex regional pain syndrome, failed back surgery syndrome, and rheumatoid arthritis are well-defined pain diagnoses that have been historically treated with opioids. Fibromyalgia and chronic headache are more ephemeral diagnoses for which opioid management would be more controversial 2.  Determine the relative abuse and diversion risk for. each patient. It is possible to assess pre-treatment addiction risk by using screening questionnaires such as OTORI, ORT, SOAPP-R, and DIRE while screening questionnaires such as PMQ, COMM, and PDRQ may identify abuse once treatment has started. According to a 2013 VA study by Zedler et. al., the 14 item OTORI screening questionnaire may be the best tool to predict opioid overdose prior to starting treatment. The most important medical history items associated with opioid abuse include personal or family history of addiction and comorbid psychiatric conditions. 3. Identify specific, achievable patient goals for chronic pain therapy before beginning opioids. For example: The patient will go shopping for groceries without assistance once per week. The patient will attend their childs school functions twice per week. The patient will stay out of bed for at least 14 hours per day.  4. Define your opioid philosophy and rules for opioid prescribing in writing. For example: Chronic opioids will be provided to you at the lowest possible dose that relieves pain and improves function in conjunction with multidisciplinary physical and psychological therapies and referral for interventional procedure as appropriate. You agree to obtain opioids only from this medical practice. If you obtain controlled substances from any other source, you must inform us immediately. Lost and/or early prescriptions will not be refilled. Random urine drug screens will be performed. We will involve family members in the evaluation and treatment process whenever possible. Functional improvement is as important as pain relief and we will regularly measure physical function. Your patient should sign a formal Opioid Agreement, which describes your requirements and expectations for the patient. Sample opioid agreements are available online and should be reviewed and customized to your medical practice and your prescribing philosophy. 5.  Define a ceiling dose for opioids. Death rates are increased in patients who take high doses of opioids so consider a ceiling dose for the opioids you prescribe. Data from Washington State suggests that capping a maximum opioid dose at 100200 morphine mg equivalents per day can reduce overdose mortality. Combining appropriate non-addicting medications such as anti-inflammatories, acetaminophen, nerve stabilizing medications, and antidepressants will help to keep the opioid dose as low as possible. 6.  Facilitate multidisciplinary management. Chronic pain is most effectively treated when multidisciplinary resources are utilized so consider referring your patient to a physical therapist, psychologist, psychiatrist and/or an interventional pain clinic as appropriate. Regular physical therapy combined with a home exercise program will help maximize physical function. Treating anxiety, depression, and comorbid psychiatric conditions with psychological or psychiatric evaluation and therapy is equally important to the success of any pain management plan. Referral to an interventional pain clinic is appropriate for patients who may benefit from interventional procedures such as: Epidural steroid injections for disc herniation Sympathetic blocks for complex regional pain syndrome Medial branch radiofrequency ablation for axial spine pain of facet origin Spinal cord stimulation for intractable neuropathic pain Implant of an intrathecal infusion pump for targeted drug delivery in patients who are refractory to or experience unacceptable side effects from oral opioids 7.  Emphasize Prescription Monitoring Program (PMP) database checks and urine drug screening. It is important to check the PMP database before dispensing any opioid prescription and to perform urine drug screening (UDS) at baseline and randomly during opioid therapy. According to the Centers for Medicare & Medicaid Services (CMS), PMPs have resulted in improved prescribing patterns, decreased use of multiple providers and multiple pharmacies, and a reduction in substance abuse hospital admissions. Studies from Washington state and Canada have shown that PMPs in combination with UDS, patient education, pill counts, and written opioid agreements can reduce prescription opioid abuse by 50 percent. Low-risk patients may be appropriate for urine drug screening every six months whereas higher risk patients should be screened more frequently. Conclusion Finally, be sure to follow your written plan and protocols. If you continue to prescribe opioids in the face of positive urine drug screens and multiprovider prescriptions evident in the PMP, you put your patients safety and your medical license at risk. If pain is not relieved and function not improved, consider weaning opioids. Weaning protocols are available and typically include reduction of opioid dose by 10 percent to 30 percent per week depending on circumstances. If a patient is actively abusing opioids, inpatient detoxification may be appropriate. David Schultz, MD, is founder and medical director of MAPS Medical Pain Clinics and MAPS Applied Research Center. He is board-certified in anesthesiology and pain medicine.