In most patients, acute pain resolves when the affected tissue heals; however, some patients progress from acute to chronic pain in a process called pain chronification. The underlying cause(s) is/are not established but may be related to central nervous system changes in pain facilitation and inhibition. 86 Pain chronification is based on acute pain (e.g., low back, postsurgical, diabetic neuropathy) and social and psychological factors, including maladaptive pain, coping behaviors, concurrent psychiatric illness, and pain catastrophizing. Other factors associated with chronic pain include female gender, increased age, and lower household income. 86 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. 85 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. Attention to the risks of opioid use has increased as there has been a sharp decline in opioid prescriptions. Prescribing practitioners and other healthcare professionals used the state prescription drug monitoring program (PDMP) more than 910 million times in 2020. The PDMP is an electronic database that tracks controlled substance prescriptions in each state. The 2021 Overdose Epidemic report issued by the AMA in 2021 also highlights that more than 104,000 physicians and other healthcare professionals obtained 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 and less than 10% of providers were “x-waivered” during this period. 87 The requirements for the prescribing of buprenorphine have changed since this statistic, and currently no waiver is necessary to prescribe buprenorphine in all its forms for any clinician with a valid DEA license. This significantly increases the number of providers eligible to assist with OUD. Despite all the efforts to curb illicit drug use, 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. 88 In addition, state public health, media, and other reports show that drug-related overdose and death have worsened nationwide. 70
Opioid Analgesics in Acute Pain for Adults The decision of whether to use opioid analgesics for acute pain can be challenging. Not all acute pain requires management with an opioid analgesic. It can be difficult 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. 89 Riva found that in some 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. 90 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, the use of the opioid reversal agent, and the need for follow-up. 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. In terms of 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. 91 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. 92 The CDC recommends avoiding short-acting (or immediate-release) opioids as single agents for treating acute pain in opioid-naïve patients. Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as
appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. In general, long-acting opioids or extended- release formulations should be avoided for acute pain treatment. In most situations, the duration of opioid analgesic treatment for acute pain should not exceed 3 days, and more than 7 to 10 days is rarely required. 91 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/. Assessment of acute or chronic pain should be multidimensional. Consideration should be given to several domains, including the physiological features of pain and its contributing factors, with physicians and other clinicians assessing patients for function, quality of life, mental health, and emotional health. In addition to a complete medical and medication history typically obtained at an office visit, document pain intensity, location, duration, and factors that aggravate or alleviate pain. 99 Assessment of Adults for Chronic Opioid Therapy A comprehensive assessment of the patient, caregiver(s), and family member(s) is necessary to determine an appropriate chronic pain management regimen. The goal is to determine the nature of the pain and how the pain affects the function and quality of life, assess prior treatment approaches, and detect other conditions that could influence the decision to utilize opioid analgesics. 99 The assessment should include: • Nature and intensity of pain • Past and current treatment regimens and responses, including adverse effects or reactions • How pain impacts physical and psychological function • How pain influences sleep, mood, work, relationships, leisure, and substance use • Identification of concurrent conditions that may increase the risk for adverse events (e.g., obesity, renal disease, sleep apnea, COPD) • Review of current medications; identify interacting drugs and other central nervous systems (CNS) depressants • Social support, housing, employment, or recent military deployment • Patient and family history of mental health disorders (e.g., bipolar, attention deficit disorder (ADD) / attention deficit hyperactivity disorder (ADHD), depression, posttraumatic stress disorder) • Patient and family history of substance use, addiction, or dependence
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