Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
OPIOID DOSING FOR ACUTE PAIN The amount of opioid prescribed should relate to the level of pain expected from the injury or procedure. Injuries or procedures involving bones and joints tend to be more painful than those involving soft tissues. MANAGING CHRONIC NONCANCER PAIN Management of chronic noncancer pain begins by establishing individualized treatment goals, exploring nonopioid treatment options, and addressing comorbid depression and anxiety, if present. Pain management goals may include both pain and functional targets, with the understanding that being 100% pain free is not realistic. Functional goals should focus on activities that are meaningful to the patient and attainable based on the severity of the painful condition. Multimodal approaches that include nondrug (procedures, integrative treatments) and drug interventions are recommended. Comorbid conditions such as depression and anxiety can impact pain management. For patients with intractable, moderate-to-severe chronic noncancer pain unresponsive to nonopioid treatment options, a trial of opioids may be indicated guided by the following principles: • Discuss risks and benefits of opioid use • Establish a written treatment agreement • Check or monitor opioid use with the prescription drug monitoring program • Use caution with dose escalation
• Prescribe naloxone if at risk for overdose • Screen for opioid misuse or abuse using history and, ideally, a validated questionnaire, as well as urine drug testing • Taper or discontinue opioids when possible ESTABLISHING A WRITTEN TREATMENT AGREEMENT Written documentation of all aspects of a patient’s care, including assessments, informed consent, treatment plans, and provider/patient agreements, are a vital part of opioid prescription best practices. Such documentation provides a transparent and enduring record of a clinician’s rationale for a particular treatment and provides a basis for ongoing monitoring and, if needed, modifications of a treatment plan. Many computerized systems are now available for the acquisition, storage, integration, and presentation of medical information. Most offer advantages that will benefit both patients and prescribers, such as maintaining up-to-date records and providing instant availability of information relevant to prescribing or treatment. Good documentation can be achieved with the most elaborate electronic medical record systems, with paper and pen, or with dictated notes. INFORMED CONSENT Informed consent is a fundamental part of planning for any treatment, but it is particularly important in long-term opioid therapy, given the potential risks of such therapy. At its best, consent also fortifies the clinician/patient relationship.
OPIOID DOSE RECOMMENDATIONS FOR POST-PROCEDURAL PAIN Procedure
Number of oxycodone 5 mg tablets (or equivalent)
Dental extraction Thyroidectomy
0 5 5 5
Breast biopsy or lumpectomy
Lumpectomy plus sentinel lymph node biopsy
Hernia repair (minor or major)
10 10 10 15 15 15 15 20 20 30 50
Sleeve gastrectomy
Prostatectomy
Open cholecystectomy
Cesarean delivery
Hysterectomy (all types)
Cardiac surgery via median sternotomy
Open small bowel resection
Simple mastectomy with or without sentinel lymph node biopsy
Total hip arthroplasty Total knee arthroplasty
Source: [57]
Table 3
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MDUT1125
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