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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 of 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 an understanding of 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). If codeine or tramadol is used in breastfeeding women, serious adverse effects (e.g., excessive sleepiness, difficulty breastfeeding, or respiratory depression) could be fatal in the infant (FDA, 2022c). Table 5. Oral Opioids for Acute Pain in Opioid-Naive Adults Medication Available Oral Strengths Moderate Pain

The CDC recommends avoiding short-acting (or immediate- release) opioids exclusively for treating acute pain in opioid- naive 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 are rarely required (Pino & Wakeman, 2022). Healthcare Consideration: Reviewing current guidelines and 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/ 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. To reduce the overall burden of opioids, clinicians should consider nonopioid treatment modalities such as regional anesthesia, massage, and/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 and 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).

Severe Pain Clinical Considerations

Codeine– acetaminophen • Tylenol with Codeine

Tablets: • 15 mg/300 mg • 30 mg/300 mg • 60 mg/300

1 to 2 tablets every four hours as needed for pain.

• Incremental efficacy decreases and increases in adverse reactions with increasing doses. Limit codeine to no more than 60 mg/dose. Therefore, do not exceed codeine 360 mg/24 hours. • The maximum dose of acetaminophen is 4,000 mg/ day (from all sources). • Metabolism of codeine to morphine (its active form) varies between patients; drug interactions may affect response. • Dosage limited by acetaminophen maximum dose (4,000 mg/day [from all sources]).

Hydrocodone– acetaminophen

Tablets: • 2.5 mg/325 mg • 5 mg /300 mg • 5 mg/325 mg • 7.5 mg/300 mg • 7.5 mg /325 mg • 10 mg/300 mg • 10 mg/325 mg Oral solution: • 7.5 mg/325 mg per 15 mL • 10 mg/300 mg per 15 mL • 10 mg/325 mg per 15 mL

1 to 2 tablets PO every six hours as needed.

1 to 2 tablets PO every four to six hours as needed.

• Lorcet • Lortab • Norco • Vicodin

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Book Code: AUS3024

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