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Prescription of opioids for acute pain in opioid naïve patients
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Prescription of opioids for acute pain in opioid naïve patients
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Oct 31, 2017.

INTRODUCTION — 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 [1], 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 prompted re-examination and ongoing national debate about the exact best practices for prescribing opioids for acute pain, without complete consensus.

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, longer duration prescription) is associated with both greater risk of long-term use [2] 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'.)

EXCESSIVE PRESCRIPTION — 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 40 to 50 percent receive the drug from family members or friends who have leftover pills [3-5].

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 [6], and most patients save leftover pills [7-17]. As a result, large amounts of opioid tablets are available for diversion. Examples include the following:

In a survey of approximately 210 patients who underwent urologic surgery, 67 percent of patients had surplus medication after discontinuing opioid use, and 91 percent of them saved the pills [18].

A small survey study reported that 53 percent of patients who underwent cesarean delivery and 45 percent of patients discharged home after thoracic surgery took none or very few (<5 pills) of the opioid prescribed [10]. Only 17 percent of cesarean delivery patients and 29 percent of thoracic surgery patients used all or nearly all of the prescription.

A study involving 250 patients who underwent upper extremity surgery reported that most patients received a prescription for 30 opioid tablets [9]. Seventy-seven percent of patients took half or less of the prescribed pills, and 45 percent took less than five. The total number of unused tablets from these 250 patients was 4639.

Elderly adult patients need and use less opioid for treatment of acute pain than younger patients [8,19]. Because of the risks of central nervous system side effects and possible interactions with other drugs, the doses of opioids prescribed for elderly or frail patients should be reduced. (See "Treatment of persistent pain in older adults", section on 'Choice and dosing of opioid'.)  

LEVEL OF PAIN — Not all acute pain requires treatment with opioids. A major barrier to appropriate dosing of opioid analgesics is that it is difficult to predict the intensity and duration of pain after an injury or surgery. Pain varies depending on the type of injury or surgical procedure; patient demographics; cultural/ethnic factors; prior history of alcohol, drug, or opioid use; and history of anxiety or depression.

The anatomic location and type of surgery impact the degree of expected postoperative pain. In general, procedures and injuries that involve bones and joints are more painful than those that involve soft tissue [8,9,20]. A number of studies have examined the degree of pain and/or the quantity of opioid required for pain relief after specific ambulatory surgical procedures [7,8,13,14,21,22]. Most are single institution studies, and most do not report the use of non-opioid medications or analgesic techniques (eg, local anesthetic infiltration, peripheral nerve blocks). Thus, applicability to other institutions and patient populations is unclear. Examples of these studies include the following:

A prospective study involving approximately 5100 ambulatory surgical patients who received multimodal analgesia (ie, naproxen premedication, local anesthetic infiltration or regional anesthesia as appropriate) reported that the percent of patients with severe pain at 24 hours varied by the type of surgery [21]. Patients who underwent microdiscectomy were most likely to have severe pain, followed by laparoscopic cholecystectomy, shoulder surgery, elbow/hand surgery, ankle procedures, inguinal hernia repair, and knee surgery. Postoperative analgesic prescriptions were not described.

One single center study of 642 opioid naïve patients who underwent one of five common outpatient procedures evaluated the number of opioid pills that were taken for postoperative pain [7]. The number of pills necessary to supply the opioid needs of 80 percent of patients for each procedure was calculated, with doses converted to equal a 5 mg oxycodone pill. Results were as follows:

Partial mastectomy: 5 pills

Partial mastectomy with sentinel lymph node biopsy: 10 pills

Laparoscopic cholecystectomy: 15 pills

Laparoscopic inguinal hernia repair: 15 pills

Open inguinal hernia repair: 15 pills

A substantial number of patients who underwent each of the surgical procedures took no opioids postoperatively, ranging from 22 percent after open inguinal hernia repair to 82 percent after partial mastectomy. The use of non-opioid analgesics and other opioid sparing techniques was not described.

In a follow-up study this data was disseminated to clinicians, along with a recommendation to direct patients to take acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) before opioids [13]. Re-evaluation of opioid usage led to reducing the recommended prescription for partial mastectomy with sentinel lymph node biopsy to 5 pills, and only one of the 224 patients analyzed required an opioid prescription refill.

A prospective study involving 1400 patients who underwent same day upper extremity surgery reported that patients who had soft tissue procedures took a mean of 5.1 pills before discontinuing opioids, whereas those who underwent fracture related procedures took a mean of 13 pills, and 14.5 pills for joint procedures [8]. Twenty-eight percent of patients took no opioids.

CHOICE OF OPIOID — In the United States, the most commonly prescribed opioids for acute pain include oxycodone, hydrocodone, and to a lesser extent, codeine and tramadol.

Choice of drug — Overall, there is little clinical evidence to support the systematic choice of one opioid over another, either in terms of efficacy or tolerability. Oxycodone 5 mg, hydrocodone 5 mg, codeine 30 mg, and tramadol 50 mg, each in combination with acetaminophen or ibuprofen, are equally efficacious when administered for a variety of painful conditions [23-28]. We avoid the use of codeine because of wide interpatient variability in metabolism to morphine, and related incidence of adverse events and unreliable analgesia.

A universal recommendation for the choice and dose of short acting opioid cannot be made, since there are a number of drug and patient factors that must be considered, including the following:

Patient factors – Age, ethnicity, gender, hepatic and renal impairment, genetic polymorphisms, and coexisting cardiorespiratory or cerebrovascular disease [29].

Drug factors – Drug metabolism, strength of receptor binding, the potential for drug-drug interactions, co-administration with other central nervous system (CNS) depressants.

Oxycodone may be preferred rather than hydrocodone for patients who take regularly scheduled acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDS) as part of multimodal pain control, because it is available as a sole drug. In the United States, hydrocodone is only available in combination with acetaminophen or ibuprofen. Therefore, the maximum recommended doses of the non-opioid component may complicate and limit administration of hydrocodone when those medications are taken separately. Hydromorphone is another frequently used opioid for short-term analgesia, also available as a sole drug, and with clinical duration similar to oxycodone.

Short versus long acting opioid — We agree with guidelines from the Centers for Disease Control and Prevention (CDC) and other professional and governmental organizations which recommend that short acting opioids rather than long acting or extended release opioids, should be used exclusively for treatment of acute pain in opioid naïve patients. Immediate release opioids reach peak effect within 45 to 60 minutes, compared with three to four hours for controlled release (ie, slow release or prolonged release) opioids. Thus, rapid titration to effect is safer and easier with immediate release drugs. Unintentional overdose may be more likely if opioid therapy is initiated with long acting opioids. In one cohort study involving initiation of opioid therapy in approximately 840,000 opioid naïve patients over 10 years, unintentional overdose in the first two weeks was five times more likely in patients who received long acting opioids, compared with those who took short acting opioids [30].

Dose of opioid — The typical opioid prescription for acute pain consists of oxycodone 5 mg pills, or the equivalent dose of hydrocodone (5 mg) or tramadol (50 mg), and such doses appear in most opioid prescribing guidelines. The dose and prescription must be modified based on patient factors. Since it is impossible to precisely predict the response of every patient, a trial methodology calls for careful titration based on watchful observation of effect.

Morphine equivalents — A number of state, federal, and professional guidelines for opioid prescription base the recommended or allowed doses on morphine equivalents. However, there are no standard methods for opioid conversion, and available online calculators and published conversion tables provide variable and inconsistent conversion ratios [31,32]. In addition, there is wide variability among clinicians when converting opioid doses, whether they use printed or online opioid conversion tables [33]. Therefore, morphine equivalents should only be used as a general guide for starting doses, with modification based on patient factors, age, prior opioid history, and concomitant drug therapy. It is preferable to underestimate the opioid dose with a watchful approach that includes incremental dose escalation, rather than risking overestimation of dosage.

DURATION OF OPIOID THERAPY — Opioids should be prescribed in no greater quantity than that required for the expected duration of pain severe enough to require opioids. For most painful conditions unrelated to major surgery or trauma, a three day supply should suffice. A reasonable approach for pain after surgery or trauma is to prescribe enough opioid for expected pain or until a follow-up appointment is scheduled. As an example, an opioid-naïve patient who is discharged from the emergency department with a long bone fracture might be prescribed enough opioid for the three days (ie, oxycodone 5 mg or hydromorphone 2 mg, three to four times per day, 12 pills) until a follow-up appointment with an orthopedic clinician, who would evaluate and then prescribe further treatment for pain if necessary.

STRATEGY FOR PAIN CONTROL — The goal for acute pain control should not be zero pain, but rather a tolerable level of pain that allows optimal physical and emotional function. Importantly, expectations for pain related to injury, a surgical procedure, or a medical condition, should be discussed with patients and their care providers. As is always the case, the goal is to find the lowest effective analgesic dose as well as the amount needed before re-evaluation is necessary.

When possible, medical centers should create procedure specific guidelines for opioid prescription based on patient utilization data. Lacking such data, the following is a reasonable strategy for opioid prescription based on the expected level of pain.

Basic strategy for all patients with acute pain — The strategy for pain control should include the following steps for all patients:

Assessment:

Degree of expected pain (eg, mild, moderate, or severe) and duration of need for an opioid (erring on the side of small dispensations and re-evaluation if pain doesn’t resolve as expected)

Analgesics used prior to discharge, as an indication of future needs

Expectation for follow-up with primary care provider or surgeon, for reassessment of pain control

Patient factors that may affect the need for and doses of analgesics (eg, older age, comorbidities, concomitant respiratory depressants, readiness or suitability for safe use of opioids in the home, etc)

Treatment:

Utilize multimodal pain control methods, maximizing non-opioid analgesics; prescribe opioids only when necessary, and only for duration of most intense pain that is likely to require opioids.

Utilize nonpharmacologic methods of pain control (ie, ice or heat, elevation, immobilization, rest, relaxation techniques or analgesic meditation) as appropriate.

If opioids are necessary:

Check the state prescription drug monitoring database (see 'Prescription drug monitoring programs' below)

Screen for aberrant behaviors

Prescribe only short acting opioids (see 'Short versus long acting opioid' above)

Involve family members in discussions with patient on:

-Risks and benefits of opioids, with informed consent

-Realistic expectations for pain management

-Safe storage and disposal of opioids (see 'Safe storage and disposal' below)

Watch for non-analgesic use of opioids, such as for sleep or to address mood rather than pain. Address these issues directly with non-opioid options (avoiding additional respiratory depressants such as benzodiazepines).

Taper opioids as quickly as possible, while patients continue non-opioid analgesics and nonpharmacologic therapy.

Re-evaluate patients who do not follow the expected course of recovery, or require higher than expected doses of opioids.

If acute need of opioids results in prolonged use, work with patient and family to guide weaning and discontinuation of opioids.

Mild pain — Mild pain can be expected after sprains, nonspecific low back pain, dental extraction, and headaches. Opioids should not be required to adequately treat minor pain. Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase (COX)-2 inhibitors, alone or in combination, usually provide adequate pain relief in the treatment of mild to moderate pain. Generally these medications are more effective when doses are regularly scheduled (eg, acetaminophen 500 mg every four hours orally) rather than taken on an as-needed basis. NSAIDs may be more effective than acetaminophen for some types of pain (eg, dental pain [34,35]), and a combination of an NSAID with acetaminophen may be more effective than either type of drug alone for a variety of types of acute pain [34,36,37].  

Moderate pain — Most laparoscopic and minimally invasive surgery, most soft tissue surgeries, and non-compound and non-comminuted fractures are expected to result in moderate pain. In addition to regularly scheduled non-opioid analgesics, in most cases, a three day prescription of short acting opioid should suffice. This should translate into one of the following prescriptions, for patients without risk factors that require modification of the choice or dose of drug (see 'Choice of opioid' above):

3 to 4 pills of oxycodone 5 mg per day (ie, 12 tablets) or

3 to 4 pills of hydrocodone 5 mg per day (ie, 12 tablets) (available only with acetaminophen or ibuprofen) (see 'Choice of drug' above) or

3 to 4 pills of hydromorphone 2 mg per day (ie, 12 tablets) or

3 to 4 pills per day of tramadol 50 mg (ie, 12 tablets)

These opioids should be taken no more frequently than every four hours, and usually three doses per day will suffice.

For pain that is expected to last beyond three days, in our practice a five day prescription (eg, 20 tablets of oxycodone 5 mg or hydromorphone 2 mg) may be reasonable (this is an area of national debate without complete consensus). For older adult or frail patients, lower dose opioid may be sufficient (eg, oxycodone 2.5 mg). (See "Treatment of persistent pain in older adults", section on 'Choice and dosing of opioid'.)

Severe pain — Severe pain can be expected after major non-laparoscopic surgery, maxillofacial surgery, total joint replacement, compound fractures, and long bone fracture prior to definitive stabilization. In our experience, a prescription for up to seven days of higher dose opioid may be required to adequately manage pain. If follow-up can be arranged prior to seven days, the prescription should be written for the time period up until the follow-up appointment. This should translate into one of the following prescriptions, for patients without risk factors that require modification of the choice or dose of drug:

4 to 6 pills per day of oxycodone 5 mg or

4 to 6 pills per day of hydrocodone 5 mg (available only with acetaminophen or ibuprofen) (see 'Choice of drug' above) or

4 to 6 pills per day of hydromorphone 2 mg or

4 to 6 pills per day of tramadol 50 mg

PATIENT INSTRUCTION — Prior to prescribing an opioid, the clinician should discuss the goals for pain relief, risks and benefits of opioid therapy, other reasonable options for pain management, and specific instructions on taking, stopping, storing, and disposing of medication. In some states (eg, Vermont) the patient must sign a consent form for opioid treatment, both in the acute and chronic pain settings.

Expectation for pain relief — Clinicians should discuss the goals for pain relief with patients, and if appropriate, their care providers, including reasonable expectations for pain relief. The goal should be mild, tolerable pain that allows the patient to function.

Risks of opioid therapy — Clinicians should discuss the risks of dependence and overdose, side effects of opioids, and the importance of additional or alternative treatment to reduce the required dose. An example of patient instructions on prescription opioids is available on the Centers for Disease Control and Prevention (CDC) website [38].

How to take medication — The patient should receive specific instructions on the way to take opioid and non-opioid medication, including how to decrease or stop the medication. Patients should be informed that opioids should only be used when non-opioid pain medications/treatments fail to provide adequate pain relief.

Safe storage and disposal — Opioids should be stored by patients in secure locations and excess pills should be disposed of properly, to minimize the risk of diversion and inappropriate use. Patients should receive specific instruction on both issues. Most studies have reported that patients do not routinely receive instruction on storage and disposal of opioids [11,18], and most keep surplus medication at home for later use [10,12,22].

The US Food and Drug Administration (FDA) has issued guidelines for disposal of opioid medication. When possible, the FDA recommends taking excess opioids to US Drug Enforcement Agency authorized take back locations, which are often pharmacies or police stations. Alternatively, opioids can either be combined with an unpalatable substance (eg, dirt or kitty litter) and placed in a sealed a container in household trash, or flushed down the sink or toilet [39].

Written information for patients — Written information for patients in English and Spanish is available elsewhere in UpToDate. (See "Patient education: Opioids for short-term treatment of pain (The Basics)".)

EXISTING GUIDELINES AND STATE RECOMMENDATIONS — Guidance on opioid prescription for acute pain was included in the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain that was published in 2016 [40]. In addition, a number of state governments and agencies, state medical societies, and hospital systems have published guidelines, issued regulations, or passed laws that apply to the management of acute pain, including prescription of opioids. Such guidelines acknowledge that individual patient needs vary, and they typically include best practices for the following aspects of pain management:

Patient evaluation

Monitoring for the risk of substance abuse

Use of prescription drug monitoring programs

The use of multimodal pain control

Avoidance of unnecessary, excessive, or inappropriate opioid prescription

Patient education on the risks of opioid therapy, goals of therapy, and safe storage and disposal of medication  

Legislation and regulation of opioid prescription continue to evolve, and clinicians should be aware of those that are specifically applicable. Key aspects of several of the existing guidelines and laws are summarized here.

CDC – The CDC guidelines stress that opioids should be used only when necessary and in the lowest effective doses [40]. They say that if opioids are necessary, a prescription for ≤3 days will often provide pain control for nontraumatic, nonsurgical pain, and that >7 days will rarely be needed.

Washington State – Washington State published an interagency guideline in 2015 on prescribing opioids, which included recommendations for opioids in the perioperative setting [41]. In addition to recommending nonpharmacologic interventions and non-opioid analgesics, they suggest the following:

Acute postsurgical opioids should be tapered during the first few weeks after surgery

Opioids should usually be prescribed for <14 days for acute pain resulting from severe injuries or medical conditions

Prescription of opioids for nonspecific low back pain, fibromyalgia, and headaches is not supported by evidence

New concurrent prescriptions of central nervous system depressants, such as benzodiazepines, sedatives, or anxiolytics should be avoided

New York City – Similar guidelines regarding emergency department (ED) management of acute non-cancer pain were published by the New York City Department of Health and Mental Hygiene [42]. In addition to statements that opioids should be used only when necessary and in the lowest possible effective dose, the guidelines include the following statements:

Prescribe short acting opioids

Most patients require ≤3 days of opioids

Assess for risk of opioid misuse or addiction

Avoid opioids when possible for patients taking benzodiazepines

Confirm validity of lost, stolen, or destroyed prescriptions, and if appropriate, replace with a one or two day supply

Ohio – In 2012, Ohio released guidelines for opioid prescription from EDs and acute care facilities [43]. The Ohio recommendations include prescribing limitations of no more than three days and avoiding prescription of long acting opioids for acute pain [43].

Utah – The state of Utah published opioid prescribing guidelines in 2008 [44]. The recommendations regarding acute pain include the following:

Opioids should be prescribed only when non-opioid medication will not provide adequate pain relief

The quantity of opioid pills prescribed should be limited to the number of doses needed based on the expected duration of pain that would require opioids

Long acting opioids should generally not be prescribed for acute pain

The appendices include opioid dose limits for consideration of referral to a pain specialist

Vermont – The state of Vermont passed an administrative law, or rule, in 2016 that governs prescription of opioids for pain [45]. This rule applies to prescription of opioids for opioid naïve patients, and specifies separate maximum doses for adult and pediatric populations. The Vermont rule includes average daily opioid prescription limits, duration of opioid therapy, and total morphine milligram equivalents, for patients expected to have minor, moderate, severe, and extreme pain. The limits and examples of conditions associated with the categories of pain are shown in a table (table 1).

Under the Vermont rule, opioids should be prescribed for acute pain for no more than five days for moderate or severe pain, and for ≤7 days for extreme pain. Similar to other guidelines, the Vermont rule states that long acting opioids should not be prescribed for acute pain. Vermont also requires that prescribers check the prescription drug monitoring program and have the patient sign an informed consent prior to prescribing opioids.

Massachusetts – The opioid legislation enacted in Massachusetts in 2016 limits first time opioid prescription to ≤7 days, though exceptions are made for acute medical conditions [46]. Clinicians are required to check the Prescription Monitoring Program database whenever a schedule II or III opioid is prescribed, and patients are allowed to request less opioid pills than are prescribed.

PRESCRIPTION DRUG MONITORING PROGRAMS — Partially in response to problems with opioid abuse or misuse, all states except Missouri have instituted prescription drug monitoring programs (PDMPs). Some states require, and others suggest, that clinicians check the PDMP database prior to prescribing opioids. Limited study of the effectiveness of PDMPs has reported mixed results. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Prescription monitoring programs'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Opioids for short-term treatment of pain (The Basics)")

SUMMARY AND RECOMMENDATIONS

Opioid use for acute pain is associated with long-term opioid use, and 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 required. (See 'Risk of long-term opioid use' above.)

Excessive-prescription of opioids frequently results in leftover pills, which are available for diversion and inappropriate use. (See 'Excessive prescription' above.)

The degree and duration of acute pain may be difficult to predict, and is affected by the type of surgery or injury and patient factors. In general, procedures and injuries that involve bones and joints are more painful than those that involve soft tissues. (See 'Level of pain' above.)

Oxycodone 5 mg, hydromorphone 2 mg, hydrocodone 5 mg, and tramadol 50 mg, each in combination with acetaminophen or ibuprofen, are equally efficacious when administered for a variety of painful conditions. We avoid the use of codeine because of wide interpatient variability in metabolism to morphine, and related incidence of adverse events and unreliable analgesia. (See 'Choice of drug' above.)

We recommend avoiding long acting or extended release opioid prescribing for acute pain in opioid naïve patients. Rather, we recommend that when opioids are appropriate for acute pain, short acting or immediate release opioids should be used (Grade 1C). (See 'Short versus long acting opioid' above.)

Rapid titration to effect is easier and safer with immediate release opioids, which reach peak effect much more quickly than extended release drugs. The duration of adverse effects may be shorter as well.

The goal for pain control should be a tolerable level of pain that allows optimal physical and emotional function. The pain control strategy for patients with any degree of acute pain should include the following (see 'Basic strategy for all patients with acute pain' above):

Assessment of the level of pain, analgesic use prior to discharge, and options for follow-up.

Treatment with a multimodal, opioid sparing strategy that includes non-opioid pharmacologic (eg, acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDS]) and nonpharmacologic therapies (eg, ice, rest, immobilization).

If opioids are necessary, the Prescription Drug Monitoring Database should be checked, opioids should be tapered as quickly as possible, and patients should receive specific instructions on the use, discontinuation, storage, and disposal of opioids. (See 'Patient instruction' above.)

For mild acute pain, opioids should generally not be used. Mild pain should be expected after sprains, nonspecific low back pain, dental extraction, and headache. Treatment should include regularly scheduled acetaminophen and/or NSAIDs, and nonpharmacologic therapy. (See 'Mild pain' above.)

For moderate pain (eg, after most laparoscopic or minimally invasive surgery, most soft tissue surgery, non-compound and non-comminuted fractures), in most cases a three day course of oxycodone (ie, 9 tablets of oxycodone 5 mg) should provide adequate pain relief. For pain expected to last beyond three days, in appropriate cases, a five day prescription (ie, 15 tablets of oxycodone 5 mg) is reasonable. (See 'Moderate pain' above.)

For severe pain (eg, after discharge from major non-laparoscopic surgery, maxillofacial surgery, total joint replacement, compound fracture, long bone fracture prior to definitive stabilization) prescription of higher dose opioid may be required (eg, 4 to 6 tablets of oxycodone 5 mg per day) for up to seven days, or until follow-up visit at less than seven days. (See 'Severe pain' above.)

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  46. https://malegislature.gov/Bills/189/House/H4056.
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