_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
TENNESSEE DEPARTMENT OF HEALTH GUIDANCE
AFTER SURGERY Perioperative pain should be managed through a combination of targeted methods that includes management of patient expectation and anxiety, activity and mobilization when appropriate, and a trial of non-opioid pain medication for mild-to-moderate pain and opioid medication for severe pain [94]. Postoperative acute or intermittent pain analgesia often requires frequent titration. A 2- to 4-hour analgesic duration with short-acting hydrocodone, morphine, or oxycodone is more effective than extended-release formulations. Short-acting opioids are also recommended in patients who are medically unstable or with highly variable pain intensity [13; 14; 15]. PALLIATIVE CARE AND PAIN AT THE END OF LIFE Unrelieved pain is the greatest fear among people with a life- limiting disease, and the need for an increased understanding of effective pain management is well documented [27]. Although experts have noted that 75% to 90% of end-of-life pain can be managed effectively, rates of pain are high, even among people receiving palliative care [27; 28; 29; 30; 31; 32; 33; 34; 35; 36]. The inadequate management of pain is the result of several factors related to both patients and clinicians. In a survey of oncologists, patient reluctance to take opioids or to report pain were two of the most important barriers to effective pain relief [37]. This reluctance is related to a variety of attitudes and beliefs [27; 37]: • Fear of addiction to opioids • Worry that if pain is treated early, there will be no options for treatment of future pain • Anxiety about unpleasant side effects from pain medications • Fear that increasing pain means that the disease is getting worse • Desire to be a “good” patient • Concern about the high cost of medications Education and open communication are the keys to overcoming these barriers. Every member of the healthcare team should reinforce accurate information about pain management with patients and families. The clinician should initiate conversations about pain management, especially regarding the use of opioids, as few patients will raise the issue themselves or even express their concerns unless they are specifically asked [38]. It is important to acknowledge patients’ fears individually and provide information to help them differentiate fact from fiction. For example, when discussing opioids with a patient who fears addiction, the clinician should explain that the risk of addiction is low in the context of opioid use for cancer pain [27]. It is also helpful to note the difference between addiction and physical dependence.
In response to the emerging substance abuse epidemic, including a growing number of unintentional drug overdose deaths and an alarming number of infants born dependent on drugs and with signs of neonatal abstinence syndrome, the Tennessee Department of Health has published the Clinical Practice Guidelines for Outpatient Management of Chronic Non-Malignant Pain, last updated in 2024 [94]. In addition to recommendations for pre-treatment evaluation, initiation of prescription opioids, and ongoing opioid therapy for chronic pain, the Tennessee guidelines document includes an Appendix on practical issues relevant to pain management. Among the topics addressed are core competencies for clinician prescribers, mental health assessment tools, women’s issues, opioids and pregnancy, risk assessment tools, and prescription drug disposal. Following a review of naloxone usage and potential benefit in reversing the effects of opioid overdosing, a section regarding co-prescribing of naloxone with opioids was added to the 2020 guidelines appendix. The Tennessee Clinical Practice Guidelines for Management of Chronic Pain, 4th Edition, is available online at https:// www.tn.gov/content/dam/tn/health/healthprofboards/pain- management-clinic/ChronicPainGuidelines.pdf. PAIN SYNDROMES AND PRESCRIPTION OPIOID USE ACUTE PAIN Acute pain is defined as sudden in onset and self-limited (a duration of less than one month), often caused by injury, trauma, musculoskeletal strain, or surgery. For initial management of common, self-limited acute pain syndromes (e.g., acute low back pain), a multimodal approach is recommended, consisting of nonpharmacologic therapies (e.g., heat, massage, physical therapy), a two- to four-week trial of nonsteroidal anti-inflammatory drugs (NSAIDs), and a trial of a non-benzodiazepine muscle relaxant, if pain persists [94]. If, and when, opioids are prescribed for acute pain, clinicians should select the lowest effective dose of immediate-release opioids in a quantity no greater than that needed for the expected duration of severe pain. In most cases, three days or less will be sufficient; more than seven days will rarely be needed [10; 94]. However, it is important to note that this recommendation is based on emergency department prescribing guidelines for non-traumatic non-surgical pain [12]. It may be necessary to prescribe for longer periods in patients with acute severe pain.
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