The Oregon Health Authority has released new guidelines for prescribing opioids to patients with short-term acute pain. The guidelines include advising doctors not to consider opioids for mild to moderate pain in patients who haven't had past exposure to opioids. Doctors should also check on the patient's history of substance abuse problems, educate them about safe storage and disposal and prescribe the lowest effective dose.
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Overview
According to the Oregon Health Authority:
The guidelines address patients seen in the following domains of practice:
• Outpatient care (e.g., emergency departments; urgent care; primary care, including specialists who serve as primary care clinicians)
• Dental care
• Post-procedure/post-surgical care
Companion guidelines (being developed) will include recommendations for maximum opioid prescription amounts by severity and anticipated duration of acute pain.
Children, the elderly and those with existing medical conditions require additional considerations (e.g., weight, metabolism, organ dysfunction) when prescribing opioids. While these acute pain guidelines cannot address every age group and medical condition, most of the principles are relevant for all patients. For example, these guidelines should be used when
prescribing opioids to adolescents after dental procedures (e.g.., after third molar [wisdom tooth] extractions) or sports-related injuries in adolescents.
In general, opioids should not be considered first line therapy for mild to moderate pain in patients with limited past exposure to opioids (i.e., opioid naïve).
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If other options are not appropriate or effective for acute pain, and the clinician deems that opioids will be effective, follow these recommendations before any new opioid prescription. Avoid prescribing opioids without a direct patient to prescribing clinician assessment (e.g., face-to-face or telemedicine).
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Evaluate the patient
• Identify cause and type of the acute pain (e.g., medical condition, post-op, injury). Determine whether the pain is likely to be responsive to opioid or non-opioid therapies.
• Assess severity of pain.
• Determine likely period for recovery/duration of acute pain.
• Assess age and other medical considerations that might affect opioid dose.
• Review other medications patient may be taking for pain, such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). Note that these may cause drug interactions or produce toxic effects if taken with combination drugs, such as Tylenol 3.
• Document the results of this patient evaluation and the justification for prescribing an opioid.
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Assess patient history
• Assess patient for history of substance use disorder. Opioids should be prescribed with great caution in patients with SUD. Include specific documentation of the indication for prescribing opioids in these patients.
• Assess patient for a history of long-term opioid treatment. Review records from other providers and be aware that, for a patient who could be tapering off opioids, a new opioid prescription could jeopardize this progress.
• Coordinate with other providers who have prescribed a controlled substance (e.g., opioids, benzodiazepines) to the patient. If a patient on long-term opioids or benzodiazepines presents for an acute condition causing pain, communicate with the primary clinician overseeing the long-term opioid/benzodiazepines use.
• Assess patient’s use of alcohol or sedative medications. Be aware that these may exacerbate the sedative effects of opioids and prescribe opioids with caution in these patients.
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Check the database
• Check the Prescription Drug Monitoring Program (PDMP) to understand the patient’s prescription history before prescribing opioids.
• Take note of chronic opioid use and any concurrent prescription for a benzodiazepine or other sedative hypnotics.
The Associated Press
Educate the patient
• Counsel patient about pain and expected duration before procedures or after injuries.
• Review with patient the risks and side effects of opioids.
• Provide an opioid safety handout and review with patient before prescribing.
• Counsel patient to avoid alcohol and other sedative medications when taking opioids.
• Counsel patient that using opioid combination medications (e.g., Tylenol #2-4, Vicodin, Percocet) with over-the-counter medications (e.g., Tylenol) may lead to toxicity.
• Provide information on safe storage and disposal of unused opioid medications.
If a prescription is needed
• Use opioids with caution and only if necessary.
• Do not prescribe opioids without a direct patient to prescribing clinician assessment, or document reason for the exception.
• Prescribe the lowest effective dose of short-acting opioids usually for a duration of less than 3 days; in cases of more severe acute pain limit initial prescription to less than 7 days.
• Do not recommend a more than two-fold range of amount or timing of opioids. Never recommend dual ranges (e.g., 1–2 pills every 6 hours as needed for pain is appropriate, but 1–4 pills every 4–6 hours is not).
• If prescribing an opioid combination medication (e.g., Tylenol #3), assess patient’s use of over-the-counter medications (e.g., Tylenol) to identify and explain potential acetaminophen or NSAID toxicity.
• Do not prescribe opioids and benzodiazepines simultaneously unless there is a compelling justification.
• When pre-packaged opioids are dispensed in emergency departments, ensure that a system is in place to share information via the Prescription Drug Monitoring Program (PDMP).
* Note: These guidelines use # days’ supply as a simple method to indicate amount; however, it is a given that different medications have differing strengths. A table with recommended strengths of various medications is on page 7.
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Follow up with patients
• Recommend appropriate follow-up for all patients, depending on condition for which patient has been seen (e.g., dental, post-op).
• Before providing a refill, re-assess the patient’s pain, level of function, healing process and response to treatment. Explore other non-opioid treatment options. Do not prescribe a refill of opioids without a direct patient to prescribing clinician assessment (e.g., face-to- face, telemedicine).
• After visits to urgent care and/or the emergency department, ensure follow-up with an appropriate primary care medical or dental provider rather than providing additional opioid refills from the ED. Prescriptions opioids from the ED for severe acute injuries (e.g., fractured bones) should be in an amount that will last until the patient is reasonably able to receive follow-up care for the injury.
State Health Officer Dr. Katrina Hedberg says most people who end up using opioids in the long-term are those who started with a prescription to treat mild to moderate acute pain, such as a broken arm
Sources: The Associated Press, Oregon Health Authority
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