Opioids for acute pain: use caution Opioids are commonly prescribed for pain, with nearly two thirds (64%) of the public reporting being prescribed an opioid for pain at some point in their lives. 116 However, this approach is not as safe and effective as once thought, and high-dose prescriptions or prolonged use not only increase the risk of misuse, addiction, or overdose, they may actually increase pain and pain sensitivity. 117,118 Recent evidence suggests that opioids may not be more effective for moderate to severe acute pain than non-opioid pain regimens. 119,120 A randomized trial of 416 patients with acute extremity pain found no clinically important differences in pain reduction at two hours after single-dose treatment with ibuprofen and acetaminophen vs. three different opioid and acetaminophen combination analgesics. 113 Physical dependence can readily occur after use of opioids at a sufficient dose (e.g., 30mg of oxycodone) for just a few days. In addition, side effects of opioid use can include constipation, confusion/gait instability, respiratory depression, pruritus, erectile dysfunction, and fractures, all of which may be more problematic in older patients and occur at higher rates than with non- opioid analgesics. A cross-sectional study compared common side effects experienced during the first week of treatment with opioid analgesics vs. non-opioid analgesics in patients over age 65 with acute musculoskeletal pain. 121 The intensity of six common opioid-related side effects were significantly higher with opioids. (A limitation of this study is that it could not assess severe but less common adverse events associated with NSAIDs and acetaminophen, including the risk for gastrointestinal bleeding, acute kidney injury, and hepatotoxicity.) In a retrospective study of 12,840 elderly patients with arthritis, opioid use was associated with an increased risk relative to non-opioids for cardiovascular events, fracture, events requiring hospitalization, and all-cause mortality. 122 The risk of prolonged opioid use is particularly high after arthroscopic joint procedures. In a 2019 case-control study of 104,154 opioid-naïve adults, 8,686 (8.3%) developed new prolonged opioid use
(continued opioid use between 91 and 180 days after shoulder arthroscopy). 123 Subgroups at higher risk for long-term use included women, those with a history of alcohol use disorder, those with a mood disorder, and
those with an anxiety disorder. Opioid choices for acute pain
If an opioid is deemed necessary to treat moderate-to- severe acute pain, the following general principles are recommended when starting an opioid: ● Avoid extended-release and long-acting opioids such as methadone, fentanyl patches, and ER/ LA versions of opioids such as oxycodone or oxymorphone. ● Avoid co-prescribing opioids with other drugs known to depress central nervous system function (e.g., benzodiazepines) ● Limit the dose and quantity of opioids to address the expected duration and severity of pain (usually less than 7 days). ● Combine opioids with other treatments (e.g., non-pharmacologic options such as exercise or cognitive behavioral therapy, NSAIDs, or acetaminophen). ● Closely monitor patients with impaired hepatic or kidney function if they are prescribed opioids, and adjust the dose or duration accordingly. Immediate-release agents are strongly preferred because of the higher risk of overdose associated with ER/LA agents. A cohort study of 840,000 opioid-naïve patients over a 10-year span found that unintentional overdose was 5 times more likely in patients prescribed ER/LA agents compared to immediate- release opioids. 124 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. 125 Table 3 illustrates the wide range of expected pain and associated recommended opioid doses for some common surgeries or procedures.
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Book Code: MDAZ1124
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