__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
Acute Pain Recommendation 4: Prescribe Immediate- release/Short-acting Opioids (IR/SA) When opioids are indicated for the treatment of acute pain, prescribe immediate-release/short-acting (IR/SA) opioids. Extended-release/long-acting (ER/LA) opioids, including methadone, should rarely, if ever, be prescribed for acute pain, including post-operative pain. Severe acute pain that persists longer than the expected healing time warrants re-examination. Patients with acute pain who fail to recover in a usual timeframe or otherwise deviate from the expected clinical course for their diagnosis should be carefully evaluated. The continuation of opioid treatment in this situation may represent the initiation of opioid treatment for a chronic pain condition. The diagnosis and appropriateness of interventions should be re-evaluated and the patient’s medical history should be reviewed for comorbidities that could interact with opioid treatment and for risk factors during opioid treatment, including current or history of substance use disorder. It is also recommended that the prescriber check the Utah Controlled Substance Database at the time they prescribe an opioid. Acute Pain Recommendation 5: Prescribe the Lowest Effective Dose When opioid medications are prescribed for treatment of acute pain, prescribers should prescribe the lowest effective dose and no more than the number needed for the usual duration of pain associated with that condition, usually 3-5 days and rarely more than seven days. Utah law states, “an opiate...issued for an acute condition shall be completely or partially filled in a quantity not to exceed a seven-day supply as directed on the daily dosage rate of prescription.” The exception is a surgery when the surgeon determines more is needed, in which case up to a 30-day supply may be prescribed, with a partial fill at the prescriber’s discretion (Utah Code 58-37-6 (7) iii, effective May 9, 2017). Prescribing more medication than the amount likely to be needed leads to unused medications being available for abuse or diversion. Use of opioid pain medications should be stopped when pain severity no longer requires opioid medications and when function and quality of life has improved. Acute Pain Recommendation 6: Avoid and Counsel Against Combining Opioids with CNS Depressants Avoid prescribing, and counsel against, concurrent use of opioids and benzodiazepines. Patients should also be counseled against concurrent use of opioids with other sedating substances, including alcohol muscle relaxant drugs, and sedative hypnotics including prescription and over-the- counter sleep aids, etc. Concurrent use of alcohol, benzodiazepines, and other CNS depressants increases the risk of respiratory depression, which can potentially cause death.
Concurrent use of benzodiazepines requires explicit medical justification due to the serious risk of respiratory depression. For putative psychiatric indications, psychiatric consultation should be sought to treat the patient’s condition with potentially less toxic drug-to-drug interactions. Prescribers should warn patients of the high-risk interaction of opioids and CNS depressants. Acute Pain Recommendation 7: Counsel Patients on the Risks of Opioid The patient should be counseled on the risks of taking opioids that including dependency, addiction, and death. In addition, patients should be advised of the signs of an opioid overdose and informed of Utah Clinical Guidelines on Prescribing Opioids for the Treatment of Pain the availability of naloxone. Patients should be encouraged to securely store their medications, not share with others, and to dispose of opioids properly when the pain has resolved to prevent non-medical use of the medications. Patients and family/caregivers should learn to recognize the signs of an opioid overdose: • Extremely pale face and/or feels clammy to the touch • Body goes limp • Fingernails or lips have a purple or blue color • Vomiting or making gurgling noises • Unable to be awakened or unable to speak • Breathing or heartbeat slows or stops For patient education materials and resources on the risks of taking opioids and signs of an opioid overdose, visit www. opidemic.org. For information on safe storage and disposal, visit www. useonlyasdirected.org. For information on naloxone information, visit naloxone.utah.gov/. CHRONIC PAIN OPIOID TREATMENT RECOMMENDATIONS PRIOR TO PRESCRIBING OPIOIDS (1.1 – 3.3) Chronic Pain Recommendation 1: Assessment Recommendation 1.1: Use Non-pharmacologic and Non- opioid Pharmacologic Therapies as Alternative Treatments to Opioids Opioid medications should only be used for treatment of chronic pain when the severity of the pain warrants that choice and after determining that other non-opioid pain medications or therapies are either contraindicated or will not provide adequate pain relief. Unless contraindicated, non- opioid analgesics, adjuvant analgesics (e.g., anticonvulsants, antidepressants, non-steroidal anti-inflammatory drugs [NSAIDs], corticosteroids) and non-pharmacologic therapies (e.g., cognitive behavioral therapy, physical therapy) are the preferred method of treatment of chronic pain.
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