Opioid analgesics in acute pain for adults The decision of whether to use opioid analgesics for acute pain is difficult. Not all acute pain requires management with an opioid analgesic. It can be challenging to predict the intensity and dura- tion of pain after an injury. Overprescribing opioids results in ex- cess 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 (Kene et al., 2022). Riva et al. (2020) found that 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. The prescriber must use clinical judgment and customize the care to the individual patient. Further, they should assess patient fac- tors affecting pain management therapy (e.g., age, concurrent re- spiratory depressants, comorbid conditions), prior analgesic use, and degree and duration of expected pain requiring opioid anal- gesics. Additionally, prescribers should review the PDMP as part of their assessment process. Adjunctive therapy, such as physi- cal therapy, should be explored with the patient. Counseling pa- tients, caregivers, and other family members is essential to ensure realistic expectations, along with understanding the benefits of opiate therapy, proper use, storage and disposal, and the need for follow-up (Pino & Wakeman, 2022). Common opioids for acute pain include oxycodone, hydroco- done, tramadol, and codeine. As the metabolism of codeine to morphine, the active form, may be variable, leading to incom- plete pain relief, codeine is not a drug of choice for acute pain management. Regarding 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 acetamino- phen or ibuprofen. It is important to note that the maximum rec- ommended doses of acetaminophen and ibuprofen may limit the administration of the combination products. Oxycodone and hy- dromorphone as single-ingredient products may be alternatives when maximum dose limits prevent continued use of combination products (Pino & Wakeman, 2022). Serious adverse effects (e.g., excessive sleepiness, difficulty breastfeeding, or respiratory de - pression) could be fatal in the infant if codeine or tramadol is used in breastfeeding women (FDA, 2022c). The CDC recommends avoiding short-acting (or immediate-re- lease) opioids exclusively for treating acute pain in opioid- naïve patients; long-acting opioids or extended-release formulations should be avoided. In most situations, opioid analgesic treatment for acute pain should not exceed three days, and more than seven to ten days is rarely required (Pino & Wakeman, 2022). Self-Assessment Quiz Question #3 If the prescriber institutes long-term opioid therapy, a written informed consent and treatment agreement are recommended. The informed consent may address which of the following? a. Potential risks and benefits of opioid therapy. b. Potential short- and long-term side effects of opioid therapy. c. Risk of drug interactions and oversedation. d. Risk of impaired motor skills. e. All of the above.
Healthcare Consideration: 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/. To reduce the overall burden of opioids, clinicians should consider nonopioid treatment modalities such as regional anesthesia, mas- sage, or physical therapy. Follow-up within three to five days of initial treatment is essential. Reevaluate any severe pain that con- tinues beyond the expected duration to adjust the pain manage- ment regimen appropriately. Consider a stepwise approach with the least invasive and least powerful pain management therapies appropriate for the patient (see Table 5). Counsel patients regarding common adverse effects of opioids used for acute pain. Upon initiation of opioid therapy, it is com- mon for patients to experience sedation, nausea or vomiting, and pruritus. In most cases, these effects resolve within a few days. It is important to note that opioid-induced itching does not always indicate an allergic reaction, as opioids induce the release of his- tamine. Treatment with antihistamines usually resolves the itching but may increase sedation. Ensure patients are aware of the risk of oversedation, respiratory depression, and overdose, and recom- mend that they not take more medication than prescribed without discussing it with their prescriber. The FDA approved the Opioid Analgesic Risk Evaluation and Mitigation Strategies (REMS), which apply to all opioid analgesics for outpatient use. The REMS program requires that training be made available to all healthcare providers involved in managing patients with pain, including nurses and pharmacists (FDA, 2021). Prescribers are strongly encouraged to do all of the following: ● Complete a REMS-compliant education program offered by an accredited continuing education (CE) provider or another education program that includes all the elements of the FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain. ● Use the patient counseling guide (PCG) to discuss the safe use, serious risks, and proper storage and disposal of opioid analgesics with patients and their caregivers. ● Emphasize to patients and their caregivers the importance of reading the medication guide provided by their pharmacist every time an opioid analgesic is dispensed to them. ● Consider using other tools to improve patient, household, and community safety, such as patient–prescriber agreements that reinforce patient–prescriber responsibilities. Give special safety instructions to patients with young children, especially toddlers, and those who live with a child or adult who is cognitively impaired. For example, prescribing a controlled sub- stance to a patient with Alzheimer’s disease or other cognitive impairments must involve instructions to a responsible adult in the home. Family members should also have a plan for accidental overdoses, including poison control (1-800-222-1222) for unintentional inges- tion of a known or unknown substance. Family members should call 911 and initiate emergency services if the individual is in re- spiratory distress.
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