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Prescription of opioids for acute pain in opioid naïve patients

Carlos A Pino, MD
Melissa Covington, MD
Section Editor
Scott Fishman, MD
Deputy Editor
Marianna Crowley, MD


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".)


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 [3], and most patients save leftover pills [4-13]. As a result, large amounts of opioid tablets are available for diversion. Examples include the following:


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Literature review current through: Jul 2017. | This topic last updated: Aug 10, 2017.
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