Table 10. Oral Opioids for Acute Pain in Opioid-Naïve Adults (Continued)
Medication
Available Oral Strengths
Moderate Pain
Severe Pain
Clinical Considerations
Hydromorphone* • Dilaudid
Tablets: 2 mg, 4 mg, 8 mg
2 to 4 mg PO every 4 to 6 hours as needed
Used only for severe, acute pain, not as a first-line acute pain agent. Start with a low dose and titrate carefully.
Oral solution: 5 mg/5 mL Tablets: 15 mg, 30 mg Oral Solution: 10 mg/0.5 mL 10 mg/5 mL 20 mg/5 mL 20 mg/5 mL 100 mg/5 mL
Morphine* (Only available as generic)
10 to 30 mg PO every 4 hours as needed
Utilized only for severe, acute pain; not a first-line acute pain agent. Start with a low dose and titrate carefully.
Oxycodone* • Oxaydo • Roxicodone • Roxybond
Capsules: 5 mg
5 to 15 mg PO every 4 to 6 hours
Utilized only for severe, acute pain; not a first-line acute pain agent. Start with low a dose and titrate carefully.
Tablets: 5 mg 7.5 mg 10 mg 15 mg 20 mg 30 mg
Oral Solution: 5 mg/5 mL 20 mg/5 mL 100 mg/5 mL Tablets: 50 mg
Tramadol (Ultram)
1 to 2 tablets PO every 4 to 6 hours as needed
Maximum dose (<75 years): 400 mg/ day Maximum dose (75 years and older): 300 mg/day
*Note: Avoid extended-release formulations and long-acting opioids in acute pain.
• Determination of any history of physical, emotional, or sexual abuse and risk factors for substance abuse disorder; validated screening tools for substance abuse disorder help determine a patient’s risk level • Review of PDMP results • Monitoring of PDMP regularly throughout chronic pain management follow-up to determine if the patient obtains other controlled substance prescriptions from other providers The patient-specific treatment plan should be developed and reviewed regularly to ensure that both the clinician and patient agree on the goals of the therapy, treatment regimen, and options. Consider different treatment modalities, such as an interventional approach, a formal pain rehabilitation program, physical medicine, psychological and behavioral strategies, or medications (nonopioids and opioids), depending upon the physical and psychosocial issues related to the pain. Opioid therapy is not the appropriate Informed Consent and Treatment Plans for Chronic Opioid Treatment
first-line treatment for most patients with chronic pain. It should be reserved for intractable chronic pain that is not adequately managed with more conservative or interventional methods. Other nonopioid medications, treatment modalities, and nonpharmacological therapy should be tried first. Practitioners should document the effectiveness or failure of these medications before initiating opioid therapy. 100 Suppose the prescriber determines that an opioid trial is an appropriate treatment option. In that case, the patient, caregiver(s), and family member(s) are informed of the risks and benefits of opioid analgesic therapy and the conditions under which the opioids are being prescribed. A trial implies that opioids are used for a short period (i.e., weeks or a couple of months), and continued use will be contingent upon demonstrated improvement in pain, physical function, and quality of life with no significant adverse reactions or aberrant behaviors. 101 If the prescriber institutes long-term opioid therapy, a written informed consent and treatment agreement are recommended.
The informed consent may address several issues, such as the following: • Limited evidence of the benefit of opioids or other medications in managing chronic pain (except for cancer) • Potential risks and benefits of opioid therapy • Potential short- and long-term side effects of opioid therapy • The likelihood that tolerance to and physical dependence on the medication will develop • Risk of drug interactions and oversedation • Risk of impaired motor skills • Risk of substance abuse disorder, overdose, and death • The clinician’s prescribing policies (e.g., number and frequency of refills, early refills, exceptions) • Reasons a drug may be changed or discontinued; treatment may be discontinued without agreement from the patient, such as violations of the treatment agreement • Education for patients stating that complete elimination of pain should not be expected
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