Prescription of opioids for acute pain in opioid naïve patients
- Carlos A Pino, MD
Carlos A Pino, MD
- Associate Professor
- University of Vermont College of Medicine
- Melissa Covington, MD
Melissa Covington, MD
- Assistant Professor of Anesthesiology
- University of Vermont College of Medicine
Opioids are often prescribed for acute postoperative pain and other painful conditions for patients in the emergency department and primary care settings. Patients deserve pain relief; adequate relief of pain is a metric of patient satisfaction and may prevent chronic postsurgical pain. However, opioid use for acute pain is associated with increased risk of long-term opioid use, which in turn is associated with death from overdose. The soaring increase in opioid prescriptions in the United States is a driver of the epidemic of drug overdose deaths. This public health epidemic has driven re-examination and ongoing national debate about the exact best practice in prescribing opioids for acute pain, without complete consensus at this time.
This topic will discuss the rationale for limitation of opioid prescriptions and will provide a strategy for prescription of opioids for acute pain in opioid naïve patients in the outpatient setting. "Opioid naïve" is variably defined in the literature. For the purpose of this topic, opioid naïve patients are those who have not received opioids in the 30 days prior to the acute event or surgery. Treatment of acute pain for patients chronically using opioids, and for inpatients after surgery, are discussed separately. (See "Management of acute pain in the patient chronically using opioids" and "Management of acute perioperative pain".)
RISK OF LONG-TERM OPIOID USE
Prescribing opioids for acute pain is associated with a greater likelihood of long-term opioid use. Further, a greater amount of initial opioid exposure (ie, higher total dose) is associated with both greater risk of long-term use and greater risk of overdose. Thus, opioids should be prescribed only when necessary, in the lowest effective dose, and for the shortest duration necessary. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Opioid analgesics' and "Prevention of lethal opioid overdose in the community", section on 'Epidemiology of overdose' and "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Limiting dose and early refills'.)
Overprescription of opioids results in leftover pills, which are then available for diversion and inappropriate use. Among those who abuse opioids, over 70 percent obtain opioids through diversion, and over half receive the drug from family members or friends who have leftover pills [1,2].
Multiple studies have shown that excessive opioid medications are routinely prescribed for all types of surgical procedures, as well as after emergency department visits for painful conditions , and most patients save leftover pills [4-13]. As a result, large amounts of opioid tablets are available for diversion. Examples include the following:
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Aug 10, 2017.References
- Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of national findings. Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586; Findings, Substance Abuse and Mental Health Services Administration, Rockville, MD 2010.
- Manchikanti L, Helm S 2nd, Fellows B, et al. Opioid epidemic in the United States. Pain Physician 2012; 15:ES9.
- Barnett ML, Olenksi AR, Jena AB. Opioid Prescribing by Emergency Physicians and Risk of Long-Term Use. N Engl J Med 2017; 376:1896.
- Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Ann Surg 2017; 265:709.
- Kim N, Matzon JL, Abboudi J, et al. A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines. J Bone Joint Surg Am 2016; 98:e89.
- Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am 2012; 37:645.
- Bartels K, Mayes LM, Dingmann C, et al. Opioid Use and Storage Patterns by Patients after Hospital Discharge following Surgery. PLoS One 2016; 11:e0147972.
- Silvestre J, Reddy A, de la Cruz M, et al. Frequency of unsafe storage, use, and disposal practices of opioids among cancer patients presenting to the emergency department. Palliat Support Care 2016; :1.
- Tanabe P, Paice JA, Stancati J, Fleming M. How do emergency department patients store and dispose of opioids after discharge? A pilot study. J Emerg Nurs 2012; 38:273.
- Hill MV, Stucke RS, McMahon ML, et al. An Educational Intervention Decreases Opioid Prescribing After General Surgical Operations. Ann Surg 2017.
- Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug Alcohol Depend 2016; 168:328.
- Bateman BT, Cole NM, Maeda A, et al. Patterns of Opioid Prescription and Use After Cesarean Delivery. Obstet Gynecol 2017; 130:29.
- Osmundson SS, Schornack LA, Grasch JL, et al. Postdischarge Opioid Use After Cesarean Delivery. Obstet Gynecol 2017; 130:36.
- Bates C, Laciak R, Southwick A, Bishoff J. Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice. J Urol 2011; 185:551.
- Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg 1997; 85:808.
- Waljee JF, Zhong L, Hou H, et al. The Use of Opioid Analgesics following Common Upper Extremity Surgical Procedures: A National, Population-Based Study. Plast Reconstr Surg 2016; 137:355e.
- McGrath B, Elgendy H, Chung F, et al. Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth 2004; 51:886.
- Harris K, Curtis J, Larsen B, et al. Opioid pain medication use after dermatologic surgery: a prospective observational study of 212 dermatologic surgery patients. JAMA Dermatol 2013; 149:317.
- Marco CA, Plewa MC, Buderer N, et al. Comparison of oxycodone and hydrocodone for the treatment of acute pain associated with fractures: a double-blind, randomized, controlled trial. Acad Emerg Med 2005; 12:282.
- Slawson D. No Difference Between Oxycodone/Acetaminophen and Hydrocodone/Acetaminophen for Acute Extremity Pain. Am Fam Physician 2016; 93:411.
- Chang AK, Bijur PE, Holden L, Gallagher EJ. Comparative Analgesic Efficacy of Oxycodone/Acetaminophen Versus Hydrocodone/Acetaminophen for Short-term Pain Management in Adults Following ED Discharge. Acad Emerg Med 2015; 22:1254.
- Chang AK, Bijur PE, Munjal KG, John Gallagher E. Randomized clinical trial of hydrocodone/acetaminophen versus codeine/acetaminophen in the treatment of acute extremity pain after emergency department discharge. Acad Emerg Med 2014; 21:227.
- Palangio M, Morris E, Doyle RT Jr, et al. Combination hydrocodone and ibuprofen versus combination oxycodone and acetaminophen in the treatment of moderate or severe acute low back pain. Clin Ther 2002; 24:87.
- Litkowski LJ, Christensen SE, Adamson DN, et al. Analgesic efficacy and tolerability of oxycodone 5 mg/ibuprofen 400 mg compared with those of oxycodone 5 mg/acetaminophen 325 mg and hydrocodone 7.5 mg/acetaminophen 500 mg in patients with moderate to severe postoperative pain: a randomized, double-blind, placebo-controlled, single-dose, parallel-group study in a dental pain model. Clin Ther 2005; 27:418.
- Cepeda MS, Farrar JT, Baumgarten M, et al. Side effects of opioids during short-term administration: effect of age, gender, and race. Clin Pharmacol Ther 2003; 74:102.
- Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med 2015; 175:608.
- Shaheen PE, Walsh D, Lasheen W, et al. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manage 2009; 38:409.
- Shaw, k, Fudin, J . Shaw K, Fudin J. Evaluation and comparison of online equianalgesic opioid dose conversion calculators. Pract Pain Manag 2013; 13:61.
- Rennick A, Atkinson T, Cimino NM, et al. Variability in Opioid Equivalence Calculations. Pain Med 2015.
- Bailey E, Worthington HV, van Wijk A, et al. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth. Cochrane Database Syst Rev 2013; :CD004624.
- Smith EA, Marshall JG, Selph SS, et al. Nonsteroidal Anti-inflammatory Drugs for Managing Postoperative Endodontic Pain in Patients Who Present with Preoperative Pain: A Systematic Review and Meta-analysis. J Endod 2017; 43:7.
- Merry AF, Gibbs RD, Edwards J, et al. Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial. Br J Anaesth 2010; 104:80.
- Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010; 110:1170.
- Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA 2016; 315:1624.
- www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf (Accessed on January 05, 2017).
- www1.nyc.gov/assets/doh/downloads/pdf/basas/opioid-prescribing-guidelines.pdf (Accessed on January 05, 2017).
- www.opioidprescribing.ohio.gov/OOAT_RX_Guidelines.html (Accessed on January 05, 2017).
- www.health.utah.gov/prescription/pdf/guidelines/final.04.09opioidGuidlines.pdf (Accessed on January 05, 2017).
- www.healthvermont.gov/sites/default/files/documents/2016/12/REG_opioids-prescribing-for-pain.pdf (Accessed on January 05, 2017).
- RISK OF LONG-TERM OPIOID USE
- EXCESSIVE PRESCRIPTION
- LEVEL OF PAIN
- CHOICE OF OPIOID
- Choice of drug
- Short versus long acting opioid
- Dose of opioid
- Morphine equivalents
- DURATION OF OPIOID THERAPY
- STRATEGY FOR PAIN CONTROL
- Basic strategy for all patients with acute pain
- Mild pain
- Moderate pain
- Severe pain
- PATIENT INSTRUCTION
- Expectation for pain relief
- Risks of opioid therapy
- How to take medication
- Safe storage and disposal
- EXISTING GUIDELINES AND STATE RECOMMENDATIONS
- PRESCRIPTION DRUG MONITORING PROGRAMS
- SUMMARY AND RECOMMENDATIONS