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. 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. 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 avoiding short-acting (or immediate- release) opioids exclusively 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/. To reduce the overall burden of opioids, clinicians should consider nonopioid treatment modalities such as regional anesthesia, massage, or physical therapy. Follow-up within three to five days of initial treatment is essential. Reevaluate any severe pain that continues beyond the expected duration to adjust the pain management regimen appropriately. Consider a stepwise approach with the least invasive and least powerful pain management therapies appropriate for the patient (see Table 5). Counsel patients regarding common adverse effects of opioids used for acute pain. Upon initiation of opioid therapy, it is common for patients to experience sedation, nausea or vomiting, and pruritus. In most cases, these effects resolve within a few days. It is important to note that opioid-induced itching does not always indicate an allergic reaction, as opioids induce the release of histamine. Treatment with antihistamines usually resolves the itching but may increase sedation. Ensure patients are aware of the risk of oversedation, respiratory depression, and overdose, and recommend that they not take more medication than prescribed without discussing it with their prescriber. The FDA approved the Opioid Analgesic Risk Evaluation and Mitigation Strategies (REMS), which apply to all opioid analgesics for outpatient use. The REMS program requires that training be made available to all healthcare providers involved in managing patients with pain, including nurses and pharmacists (FDA, 2021). Prescribers are strongly encouraged to do all of the following: ● Complete a REMS-compliant education program offered by an accredited continuing education (CE) provider or another education program that includes all the elements of the FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain. ● Use the patient counseling guide (PCG) to discuss the safe use, serious risks, and proper storage and disposal of opioid analgesics with patients and their caregivers. ● Emphasize to patients and their caregivers the importance of reading the medication guide provided by their pharmacist every time an opioid analgesic is dispensed to them.
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