and mental functioning. 97 A multi-modal approach, using both drug and non-drug treatments, should be encouraged. In addition, patients should be educated about the safe storage and disposal of opioid medications. Safe use means following clinician instructions about dosing, avoiding potentially dangerous drug interactions (e.g., alcohol), and assuring full understanding of how the medication should be consumed or applied. Remind patients that opioid pain medications are sought after by many people, and, therefore, opioids should be stored in a locked cabinet or, if a locked unit is not available a place that is not obvious or easily accessed by others.
Proper disposal methods should be explained: ● Follow any specific disposal instructions on the prescription drug labeling or patient information that accompanies the medication. ● Do not flush medicines down the sink or toilet unless the prescribing information specifically instructs to do so. ● Return medications to a pharmacy, health center, or other organization with a take-back program. ● Mix the medication with an undesirable substance (e.g., used coffee grounds or kitty litter) and put it in the trash, or use special drug deactivation pouches that your health care provider may recommend.
MANAGING ACUTE PAIN
It is now becoming clear that many of the problems and risks associated with managing chronic pain with opioids are also at work in the management of acute pain with opioids. For example, a number of studies demonstrate increased risk of new persistent opioid use in opioid-naïve patients after having been prescribed opioids for acute pain. 98-101 Although the risk of opioid misuse in patients prescribed opioids for acute post-surgical or post-procedural pain is relatively small (roughly 0.6% per year) 102 , the volume of such procedures (there are well over 100 million outpatient surgeries performed each year in the United States) translates into large numbers of patients (i.e., approximately 600,000) who may develop dependence, abuse, or overdose every year. A central tenet of pain management, whether acute or chronic, is that the goal of treatment is a tolerable level of pain that allows the patient maximum physical and emotional functioning with the lowest risk of side effects, progression to chronic pain, or misuse or abuse 104 This requires an adroit balancing of patient-related factors (e.g., comorbidities, medical history, risk of abuse) and drug-related factors (e.g., potency, mechanism of action, expected side effects). A commonly recommended way to achieve this balance is with multimodal analgesia, in which several therapeutic approaches are used, each acting at different sites of the pain pathway, which can reduce dependence on a single medication and may reduce or eliminate the need for opioids and attendant risks/ side effects. 105 Multimodal analgesia (e.g., using drugs from two or more classes, or a drug plus a non-drug treatment) can produce synergistic effects, reduce side effects, or both. One example of multimodal analgesia is the use of both an NSAID and acetaminophen, plus physical approaches (e.g., cold, compression, or elevation) to manage postoperative pain. Demonstrated benefits of multimodal analgesia include earlier ambulation, earlier oral intake, and earlier hospital discharge for postoperative patients, as well as higher levels of participation in activities necessary for recovery (e.g., physical therapy). 105 Non-pharmacological treatments for acute pain When possible, non-pharmacologic methods should be used, alone or in combination with analgesics,
to manage acute pain. 106 The degree to which this is possible depends on the severity, type, and origin of the pain, but many non-pharmacological approaches can be very effective, and their use avoids the potential side effects and risks associated with pharmacological interventions. Physical methods of pain management can be helpful in all phases of care, including immediately after tissue trauma (e.g., rest, application of cold, compression, elevation) and later in the healing period (e.g., exercises to regain strength and range of motion). Physical therapy may be useful for a range of musculoskeletal issues and can be helpful in recovering from acute pain-producing traumas initially treated with other methods. A 2018 study reported that patients with low back pain who first consulted a physical therapist were less likely to receive an opioid prescription compared to those who first saw their primary care physician. 107 Exercise therapy can take many forms, including walking, swimming or in-water exercise, weight training, or use of aerobic or strength-training equipment. According to a CDC review, conditions that may improve with exercise therapy include low back pain, neck pain, hip and knee osteoarthritis pain, fibromyalgia, and migraine. 108
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Book Code: MDAZ1124
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