The nation continues to see increases in overdose due to illicit fentanyl, fentanyl analogs, methamphetamine, and cocaine, according to the U.S. Centers for Disease Control and Prevention (2022d). In addition, state public health, media, and other reports show that drug-related overdose and death have worsened nationwide (CDC, 2022d). Evidence-Based Practice: There is evidence that prescribing opioids for acute musculoskeletal injuries may result in long-term use and consequent harm. Riva et al. (2020) conducted a systematic review and meta-analysis of adults with opioid prescriptions for outpatient acute musculoskeletal injuries in an adjusted model that explored risk factors for prolonged use. The meta-analysis included 13,263,393 participants receiving prescriptions lasting more than seven days and higher morphine milligram equivalents per day. The study found that avoiding prescribing opioids for acute musculoskeletal injuries to patients with past or current substance use disorder restricted to seven days or less, and using lower doses when specified, are potentially important targets to reduce rates of opioid use. It is important to note that the maximum recommended doses of acetaminophen and ibuprofen may limit the administration of the combination products. Oxycodone and hydromorphone as single-ingredient products may be alternatives when maximum dose limits prevent continued use of combination products (Pino & Wakeman, 2022). Serious adverse effects (e.g., excessive sleepiness, difficulty breastfeeding, or respiratory depression) could be fatal in the infant if codeine or tramadol is used in breastfeeding women (FDA, 2022c). The CDC recommends using short-acting (or immediate- release) opioids for treating acute pain in opioid-naïve patients; long-acting opioids or extended-release formulations should be avoided. In most situations, opioid analgesic treatment for acute pain should not exceed three days, and more than seven to ten days is rarely required (Pino & Wakeman, 2022). Self-Assessment Quiz Question #3 If the prescriber institutes long-term opioid therapy, a written informed consent and treatment agreement are recommended. The informed consent may address which of the following? a. Potential risks and benefits of opioid therapy. b. Potential short- and long-term side effects of opioid therapy. c. Risk of drug interactions and oversedation. d. Risk of impaired motor skills. e. All of the above. Healthcare Consideration: A review of current guidelines or online references provides updated recommendations for managing acute pain following dental or surgical procedures or common emergency medical conditions. See, for example, recommendations developed by the University of Michigan (2022) at https://opioidprescribing. info/.
income (Pak et al., 2018). Chronic pain is characterized by persistent pain, disability, emotional disturbances, and social withdrawal symptoms that coexist and influence each other. The source of the pain may be known or unknown and may be considered a chronic disease syndrome (Halpape et al., 2022). The role of opioid analgesics in managing acute and chronic pain is well established, and opioid prescriptions for pain- related issues increased dramatically in the 1990s. As a result, the number of ED visits, substance-abuse treatment admissions, hospital stays, and deaths due to unintentional drug overdoses increased substantially, and this led to a significant public health issue in the subsequent decades. Opioid prescriptions decreased by 44.4% between 2011 and 2020, including a 6.9% decrease from 2019 to 2020 (AMA, 2021). Along with the sharp decline in opioid prescriptions, prescribing practitioners and other healthcare professionals used the state PDMP more than 910 million times in 2020 (AMA, 2021). The 2021 Overdose Epidemic report issued by the AMA (2021) also highlights that more than 104,000 physicians and other healthcare professionals have an X-waiver to allow them to prescribe buprenorphine for the treatment of opioid use disorder. This is an increase of 70,000 providers since 2017, yet 80% to 90% of people with a substance use disorder receive no treatment (AMA, 2021). Opioid analgesics in acute pain for adults The decision of whether to use opioid analgesics for acute pain is difficult. Not all acute pain requires management with an opioid analgesic. It can be challenging to predict the intensity and duration of pain after an injury. Overprescribing opioids results in excess medication available for misuse and diversion. Studies have shown routine prescribing of excessive opioids for many types of surgical procedures and painful conditions treated in emergency departments (Kene et al., 2022). Riva et al. (2020) found that high-risk populations, that is, workers’ compensation patients receiving disability benefits, Veterans Affairs claimants, and patients with a high prevalence of comorbid substance use disorder, were more likely to be on prolonged opioid use after a prescription for an acute musculoskeletal injury. Past or present substance abuse was the strongest indicator for prolonged opioid use. Therefore, it is essential to counsel patients regarding appropriate pain control and realistic expectations of pain management. The prescriber must use clinical judgment and customize the care to the individual patient. Further, they should assess patient factors affecting pain management therapy (e.g., age, concurrent respiratory depressants, comorbid conditions), prior analgesic use, and degree and duration of expected pain requiring opioid analgesics. Additionally, prescribers should review the PDMP as part of their assessment process. Adjunctive therapy, such as physical therapy, should be explored with the patient. Counseling patients, caregivers, and other family members is essential to ensure realistic expectations, along with understanding the benefits of opiate therapy, proper use, storage and disposal, and the need for follow-up (Pino & Wakeman, 2022). Common opioids for acute pain include oxycodone, hydrocodone, tramadol, and codeine. As the metabolism of codeine to morphine, the active form, may be variable, leading to incomplete pain relief, codeine is not a drug of choice for acute pain management. Regarding efficacy or tolerability, evidence shows similar results for oxycodone 5 mg, hydrocodone 5 mg, codeine 30 mg, and tramadol 50 mg, each in combination with acetaminophen or ibuprofen.
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