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Prescription of opioids for acute pain in opioid naïve patients

Prescription of opioids for acute pain in opioid naïve patients
Authors:
Carlos A Pino, MD
Sarah E Wakeman, MD
Section Editor:
Scott Fishman, MD
Deputy Editor:
Marianna Crowley, MD
Literature review current through: Nov 2022. | This topic last updated: Nov 09, 2022.

INTRODUCTION — Opioids are often prescribed for acute postoperative pain and other painful conditions for patients in the emergency department and primary care settings. Patients deserve pain relief; adequate relief of pain is a core tenet of caring for patients, a metric of patient satisfaction, and may prevent chronic postsurgical pain. However, opioid use for acute pain is associated with increased risk of long-term opioid use [1,2], which is associated with risks of opioid use disorder and overdose among a minority of people exposed. The soaring increase in opioid prescriptions in the United States was a driver of the onset of the first wave of the epidemic of drug overdose deaths [3]. This public health epidemic has prompted re-examination and ongoing national debate about the exact best practices for prescribing opioids for acute pain, without complete consensus.

This topic will discuss the rationale for cautious use of opioid prescriptions and will provide a strategy for prescription of opioids for acute pain in opioid naïve patients in the outpatient setting. "Opioid naïve" is variably defined in the literature. For the purpose of this topic, opioid naïve patients are those who have not received opioids in the 30 days prior to the acute event or surgery. Treatment of acute pain for patients chronically using opioids, and for inpatients after surgery, are discussed separately. (See "Management of acute pain in the patient chronically using opioids for non-cancer pain" and "Management of acute perioperative pain in adults".)

RISK OF LONG-TERM OPIOID USE — Opioids should be prescribed only when necessary, in the lowest effective dose, and for the shortest duration necessary. Taking opioids for acute pain is associated with a greater likelihood of long-term opioid use. Further, a greater amount of initial opioid exposure (ie, higher total dose, longer duration prescription) is associated with greater risks of long-term use [4,5], misuse, and overdose [5].

Multiple studies have reported an increased risk of new persistent opioid use after prescription of opioids for acute pain in opioid naïve patients [6-14]. Even patients who undergo relatively minor low-pain surgery are at increased risk of long term opioid use [8]. As an example, an insurance database study including 36,177 opioid naïve adults who underwent surgery reported similar rates of persistent opioid use (defined as filling an opioid prescription between 90 and 180 days after surgery) after minor and major surgery (5.9 and 6.5 percent), with an incidence of 0.4 percent in a nonoperative control cohort [6]. Risk factors for persistent opioid use after surgery include preoperative pain; medical comorbidities; depression; a history of drug, alcohol, or tobacco use; lower socioeconomic status; and use of benzodiazepines or antidepressants [9-11].

Importantly, postsurgical opioid prescription in opioid naïve patients is also associated with an increase in overdose and misuse. In a retrospective database study of 1,015,116 surgical patients who had no known history of opioid misuse or ongoing opioid use, 56 percent received postoperative opioids, and misuse (defined as a diagnosis code for opioid use disorder or overdose) was identified in 0.6 percent of patients after surgery [5]. The total duration of opioid prescription was the strongest predictor of misuse. Each prescription refill was associated with a 44 percent increase in the rate of misuse, and each additional week of opioid use increased the risk of misuse by 20 percent.

While the risk of persistent opioid use after surgery is relatively low, and the risk of misuse even lower, the absolute number of patients affected is large because of the vast volume of surgical procedures performed each year. In 2010, approximately 48 million ambulatory surgical procedures were performed in the United States alone [15]. Therefore, based on study findings above, as many as 1.6 million patients in the United States could become long-term opioid users each year after ambulatory surgery alone, and as many as 160,000 may develop opioid use disorder or overdose.

Opioid misuse is discussed more fully separately. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Opioid analgesics' and "Prevention of lethal opioid overdose in the community", section on 'Epidemiology' and "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Limiting exposure'.)

EXCESSIVE PRESCRIPTION — Prescribing more opioid than necessary can result in leftover pills, which are then available for diversion and inappropriate use. Among those who engage in nonmedical prescription opioid use, over 70 percent obtain opioids without a prescription, and 40 to 50 percent receive the drug from family members or friends who have leftover pills [16-18]. Overprescription can also lead to overconsumption [19], which can cycle up to very high doses (usually without functional benefit), which is associated with an increased risk of overdose.

Multiple studies have shown that excessive opioid medications are routinely prescribed for all types of surgical procedures, as well as after emergency department visits for painful conditions [20,21], and most patients save leftover pills [22-37]. As a result, large amounts of opioid tablets are available for non-medical use. Examples include the following:

In a large retrospective population-based study of 2392 surgical patients in the state of Michigan, the median number of opioid pills prescribed postoperatively was 30 pills (equivalent to hydrocodone/acetaminophen 5/325 mg), whereas the median consumption was 9 pills [36]. Higher prescription quantity was associated with higher patient-reported consumption, though a causal relationship could not be confirmed.

A small survey study reported that 53 percent of patients who underwent cesarean delivery and 45 percent of patients discharged home after thoracic surgery took none or very few (<5 pills) of the opioid prescribed [25]. Only 17 percent of cesarean delivery patients and 29 percent of thoracic surgery patients used all or nearly all of the prescription.

A study involving 250 patients who underwent upper extremity surgery reported that most patients received a prescription for 30 opioid tablets [24]. Seventy-seven percent of patients took one-half or less of the prescribed pills, and 45 percent took less than five. The total number of unused tablets from these 250 patients was 4639.

A prospective study of 343 children who were discharged from the hospital with an opioid prescription reported that 58 percent of prescribed doses were not consumed, and only 4 percent of leftover medication was disposed of [33]. Female sex, orthopedic or Nuss procedures, and discharge pain scores ≥5/10 significantly predicted higher opioid consumption.

Over-prescription of opioids may be more of a problem in the United States than in many other countries around the world. In a prospective international study of approximately 4700 patients who underwent appendectomy, cholecystectomy, or inguinal hernia repair over a six month period during 2016 to 2017, 91 percent of patients in the United States were prescribed opioids at discharge, compared with 5 percent of non-United States patients [38]. In patients without a prior history of opioid use, the mean number of prescribed opioid pills was higher (22.5 versus 0.8), and the mean prescribed oral morphine equivalent was higher (172.7 versus 4.3 mg) in United States compared with non-United States patients. In this study, opioid prescription in the United States was compared with prescription in Lebanon, Columbia, Mexico, China, Thailand, the Netherlands, and Brazil, all countries with very low availability of opioids overall. Thus while this and other studies have found that opioid prescribing in the United States is higher than in other countries, the difference may be less when the United States is compared with other countries with higher prescription opioid availability (eg, Canada, Germany) [39].

PROTOCOLS TO REDUCE OPIOID PRESCRIPTION — A number of institutions have implemented protocols, educational programs, or feedback systems designed to reduce unnecessary opioid prescription for acute pain [28,40-44]. In general, such efforts result in reduced number of prescribed pills, without an increase in refills or reduced patient satisfaction. Examples include the following:

A retrospective study of over 600 opioid naïve patients who underwent laparoscopic cholecystectomy, thyroidectomy, or inguinal hernia repair compared patient reported outcomes in patients who participated in an opioid sparing postoperative pathway versus patients who received standard care [40]. Patients in the opioid sparing pathway used fewer opioid pills, reported less pain, and had similar satisfaction. In the opioid sparing pathway, patients received a median of 4 oxycodone tablets (5 mg) postoperatively, compared with a median of 20 tablets for patients who received standard care. Forty percent of patients in the opioid sparing pathway received no postoperative opioid prescription. Conclusions from this study are limited by lack of data on intraoperative analgesic strategies and the retrospective nature of the study.

In a single institution study of opioid prescription for 5 common surgical procedures before and after an opioid sparing educational intervention, the total number of opioid pills prescribed decreased by >50 percent, without an increase in the request for refill [28]. Educational information provided to surgeons included recommendations for the number of opioid pills that should be prescribed for each specific procedure, and the recommendation to encourage patients to use acetaminophen and nonsteroidal anti-inflammatory drugs first, and to take opioids only when necessary. The number of pills recommended was based on data previously collected at that institution, determined to have satisfied the opioid requirement for 80 percent of patients.

A small retrospective, single institution cohort study evaluated the effects of implementation of a discharge protocol that based discharge opioid prescription on the patient’s opioid consumption in the 24 hours prior to discharge [41]. Total morphine milligram equivalents (MME) for six postoperative weeks fell from 900 to 295 MME (mean difference 721, 95% Ci 127 - 1316 MME). Refill rates and patient satisfaction were similar.

LEVEL OF PAIN — Not all acute pain requires treatment with opioids. A major barrier to appropriate dosing of opioid analgesics is that it is difficult to predict the intensity and duration of pain after an injury or surgery. Pain varies depending on the type of injury or surgical procedure; prior history of alcohol, drug, or opioid use; history of anxiety or depression; and patient demographics. It is important to note that racial disparities and inequities in pain care impact the delivery of analgesia. As an example, Black Americans are undertreated for painful conditions, and racial bias, including false beliefs about the biology of Black patients, have been shown to influence decision making around acute pain management [45-47].

Older adult patients need and use less opioid for treatment of acute pain than younger patients [23,48]. Because of the risks of central nervous system side effects and possible interactions with other drugs, the doses of opioids prescribed for older adult or frail patients should be reduced. (See "Treatment of chronic non-cancer pain in older adults", section on 'Choice and dosing of opioid'.)

The anatomic location and type of surgery impact the degree of expected postoperative pain. In general, procedures and injuries that involve bones and joints are more painful than those that involve soft tissue [23,24,49]. A number of studies have examined the degree of pain and/or the quantity of opioid required for pain relief after specific ambulatory surgical procedures [22,23,28,29,50,51]. Most are single institution studies, and most do not report the use of non-opioid medications or analgesic techniques (eg, local anesthetic infiltration, peripheral nerve blocks). Thus, applicability to other institutions and patient populations is unclear. Examples of these studies include the following:

A prospective study involving approximately 5100 ambulatory surgical patients who received multimodal analgesia (ie, naproxen premedication, local anesthetic infiltration or regional anesthesia as appropriate) reported that the percent of patients with severe pain at 24 hours varied by the type of surgery [50]. Patients who underwent microdiscectomy were most likely to have severe pain, followed by laparoscopic cholecystectomy, shoulder surgery, elbow/hand surgery, ankle procedures, inguinal hernia repair, and knee surgery. Postoperative analgesic prescriptions were not described.

One single center study of 642 opioid naïve patients who underwent one of five common outpatient procedures evaluated the number of opioid pills that were taken for postoperative pain [22]. The number of pills necessary to supply the opioid needs of 80 percent of patients for each procedure was calculated, with doses converted to equal a 5 mg oxycodone pill. Results were as follows:

Partial mastectomy: 5 pills

Partial mastectomy with sentinel lymph node biopsy: 10 pills

Laparoscopic cholecystectomy: 15 pills

Laparoscopic inguinal hernia repair: 15 pills

Open inguinal hernia repair: 15 pills

A substantial number of patients who underwent each of the surgical procedures took no opioids postoperatively, ranging from 22 percent after open inguinal hernia repair to 82 percent after partial mastectomy. The use of non-opioid analgesics and other opioid sparing techniques was not described.

In a follow-up study this data was disseminated to clinicians, along with a recommendation to direct patients to take acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) before opioids [28]. Re-evaluation of opioid usage led to reducing the recommended prescription for partial mastectomy with sentinel lymph node biopsy to 5 pills, and only one of the 224 patients analyzed required an opioid prescription refill.

A prospective study involving 1400 patients who underwent same day upper extremity surgery reported that patients who had soft tissue procedures took a mean of 5.1 pills before discontinuing opioids, whereas those who underwent fracture related procedures took a mean of 13 pills, and 14.5 pills for joint procedures [23]. Twenty-eight percent of patients took no opioids.

The opioid requirement prior to discharge after inpatient surgery may predict post-discharge opioid requirements [52], and may be used to help guide prescription [41,53]. In a single institution review of records of 333 patients who underwent a variety of abdominal procedures with postoperative hospital admission, the strongest predictor of opioid use at home after discharge was the amount of opioid used the day prior to discharge [54]. Patients who did not require opioids on the day prior to discharge took a mean of 1.5 pills after discharge. Patients who took 1 to 3 pills on the day prior to discharge took a mean of 7.6 pills after discharge, and patients who took more than 4 pills on the day prior to discharge took a mean of 21.2 pills after discharge.

CHOICE OF OPIOID — In the United States, the most commonly prescribed opioids for acute pain include oxycodone, hydrocodone, and to a lesser extent, codeine and tramadol.

Choice of drug — Overall, there is little clinical evidence to support the systematic choice of one opioid over another, either in terms of efficacy, tolerability, or risk of misuse. Oxycodone 5 mg or hydrocodone 5 mg, each in combination with acetaminophen or ibuprofen, are equally efficacious when administered for a variety of painful conditions, and are equally likely to be misused [55-60]. We avoid the use of codeine and tramadol because of wide interpatient variability in metabolism, unreliable analgesia, and related incidences of adverse events. Tramadol, which has mixed pharmacologic effects and is a weak mu opioid receptor agonist, is associated with similar adverse effects as other opioids, including risks of misuse and physiologic dependence as well as unreliable metabolism due to its dependence on unpredictable P450 hepatic conversion to an active metabolite. In an insurance database study that included over 350,000 patients who received a prescription of opioids after surgery, tramadol was associated with a higher risk of prolonged opioid use, compared with other short-acting opioids [61].

A universal recommendation for the choice and dose of short acting opioid cannot be made, since there are a number of drug and patient factors that must be considered, including the following:

Patient factors – Age, hepatic and renal impairment, genetic polymorphisms, and coexisting cardiorespiratory or cerebrovascular disease [62].

Drug factors – Drug metabolism, strength of receptor binding, the potential for drug-drug interactions, co-administration with other central nervous system (CNS) depressants.

Oxycodone may be preferred rather than hydrocodone for patients who take regularly scheduled acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDS) as part of multimodal pain control, because it is available as a sole drug. In the United States, hydrocodone is only available in combination with acetaminophen or ibuprofen. Therefore, the maximum recommended doses of the non-opioid component may complicate and limit administration of hydrocodone when those medications are also taken separately. Hydromorphone is another frequently used opioid for short-term analgesia, also available as a sole drug, and with clinical duration similar to oxycodone.

Short- versus long-acting opioid — We agree with guidelines from the Centers for Disease Control and Prevention (CDC) and other professional and governmental organizations which recommend that short-acting opioids rather than long-acting or extended release opioids, should be used exclusively for treatment of acute pain in opioid naïve patients. Immediate release opioids reach peak effect within 45 to 60 minutes, compared with three to four hours for controlled release (ie, slow release or prolonged release) opioids. Thus, rapid titration to effect is safer and easier with immediate release drugs. Unintentional overdose may be more likely if opioid therapy is initiated with long-acting opioids. In one cohort study involving initiation of opioid therapy in approximately 840,000 opioid naïve patients over 10 years, unintentional overdose in the first two weeks was five times more likely in patients who received long-acting opioids, compared with those who took short-acting opioids [63].

Dose of opioid — The typical opioid prescription for acute pain consists of oxycodone 5 mg pills, or the equivalent dose of hydrocodone (5 mg) and such doses appear in most opioid prescribing guidelines. The dose and prescription must be modified based on patient factors. Since it is impossible to precisely predict the response of every patient, a trial methodology calls for careful titration based on watchful observation of effect.

Morphine equivalents — A number of state, federal, and professional guidelines for opioid prescription base the recommended or allowed doses of morphine equivalents. However, there are no standard methods for opioid conversion, and available online calculators and published conversion tables provide variable and inconsistent conversion ratios [64,65]. In addition, there is wide variability among clinicians when converting opioid doses, whether they use printed or online opioid conversion tables [66]. Therefore, morphine equivalents should only be used as a general guide for starting doses, with modification based on patient factors, age, prior opioid history, and concomitant drug therapy. It is preferable to underestimate the opioid dose with a watchful approach that includes incremental dose escalation, rather than risking overestimation of dosage. (Related Pathway(s): Morphine milligram equivalent calculator for adults with chronic non-cancer pain.)

DURATION OF OPIOID THERAPY — Opioids should be prescribed in no greater quantity than that required for the expected duration of pain severe enough to require opioids. For most painful conditions unrelated to major surgery or trauma, a three-day supply should suffice. A reasonable approach for pain after surgery or trauma is to prescribe enough opioid for expected pain or until a follow-up appointment is scheduled. As an example, an opioid-naïve patient who is discharged from the emergency department with a long bone fracture might be prescribed enough opioid for the three days (ie, oxycodone 5 mg or hydromorphone 2 mg, three to four times per day, 12 pills) until a follow-up appointment with an orthopedic clinician, who would evaluate and then prescribe further treatment for pain if necessary.

STRATEGY FOR PAIN CONTROL — The goal for acute pain control should not be zero pain, but rather a tolerable level of pain that allows optimal physical and emotional function. Importantly, expectations for pain related to injury, a surgical procedure, or a medical condition, should be discussed with patients and their care providers. As is always the case, the goal is to find the lowest effective analgesic dose as well as the amount needed before re-evaluation is necessary.

When possible, medical centers should create procedure specific guidelines for opioid prescription based on patient utilization data [67]. Lacking such data, online tools (eg, Opioid Prescribing Recommendations for Surgery from Michigan OPEN) can be used to guide post procedure prescribing, based on current data. The following is a reasonable strategy for opioid prescription based on the expected level of pain.

Basic strategy for all patients with acute pain — The strategy for pain control should include the following steps for all patients:

Assessment:

Degree of expected pain (eg, mild, moderate, or severe) and duration of need for an opioid (erring on the side of small dispensations and re-evaluation if pain doesn't resolve as expected)

Analgesics used prior to discharge, as an indication of future needs [41,53,54,68].

Expectation for follow-up with primary care provider or surgeon, for reassessment of pain control

Patient factors that may affect the need for and doses of analgesics (eg, older age, comorbidities, concomitant respiratory depressants, readiness or suitability for safe use of opioids in the home, etc)

Treatment:

Utilize multimodal pain control methods, maximizing non-opioid analgesics; prescribe opioids only when necessary, and only for duration of most intense pain that is likely to require opioids.

Utilize nonpharmacologic methods of pain control (ie, ice or heat, elevation, immobilization, rest, relaxation techniques or analgesic meditation) as appropriate.

If opioids are expected to be necessary:

Check the state prescription drug monitoring database. (See 'Prescription drug monitoring programs' below.)

Screen for risk factors for opioid misuse (eg, personal or family history of substance use disorder, co-occurring psychiatric illness). If patient is at moderate or higher risk and opioids are necessary, consider closer monitoring during therapy.

Prescribe only short-acting opioids. (See 'Short- versus long-acting opioid' above.)

Involve family members in discussions with patient on:

-Risks and benefits of opioids, with informed consent

-Realistic expectations for pain management

-Safe storage and disposal of opioids (see 'Safe storage and disposal' below)

Watch for non-analgesic use of opioids, such as for sleep or to address mood rather than pain. Address these issues directly with non-opioid options (avoiding additional respiratory depressants such as benzodiazepines).

Taper opioids as quickly as possible, while patients continue non-opioid analgesics and nonpharmacologic therapy.

Re-evaluate patients who do not follow the expected course of recovery or require higher than expected doses of opioids.

If acute need of opioids results in prolonged use, work with patient and family to guide weaning and discontinuation of opioids.

If an opioid use disorder is identified, ensure patient has immediate access to effective addiction treatment including initiation of medication for opioid use disorder (ie, methadone, buprenorphine as first-line treatment, extended release naltrexone as a second-line option for select patients). (See "Medication for opioid use disorder".)

Discuss the availability of naloxone with patients and caregivers. In 2020 the US Food and Drug Administration (FDA) required that labels for all opioids include the recommendation that care providers discuss availability of naloxone with all patients who are prescribed opioids, and specifically consider co-prescribing naloxone for patients who take benzodiazepines or other central nervous system depressants, who have a history of prior opioid overdose, or who have household members at risk for accidental ingestion [69]. Some states (eg, California) require prescribers to offer a prescription of naloxone if the daily opioid dose is >90 MME, the opioid is prescribed with a benzodiazepine, or there is an increased risk for opioid overdose. Additionally, some states require opioid prescribers to provide education on overdose prevention, including use of naloxone.

Mild pain — Mild pain can be expected after sprains, nonspecific low back pain, dental extraction, and headaches. Opioids should not be required to adequately treat minor pain. Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase (COX)-2 inhibitors, alone or in combination, usually provide adequate pain relief in the treatment of mild to moderate pain [70]. Generally, these medications are more effective when doses are regularly scheduled (eg, acetaminophen 500 mg every four hours orally) rather than taken on an as-needed basis. NSAIDs may be more effective than acetaminophen for some types of pain (eg, dental pain [71,72]), and a combination of an NSAID with acetaminophen may be more effective than either type of drug alone for a variety of types of acute pain [71,73,74].

Moderate pain — Most laparoscopic and minimally invasive surgery, most soft tissue surgeries, and non-compound and non-comminuted fractures are expected to result in moderate pain. In addition to regularly scheduled non-opioid analgesics, in most cases, a three-day prescription of short-acting opioid should suffice. This should translate into one of the following prescriptions, for patients without risk factors that require modification of the choice or dose of drug. (See 'Choice of opioid' above.)

Note that the number of pills in parentheses refer to the number of pills to be dispensed for the entire prescription. Patients should be directed to take one tablet no more frequently than every four hours and usually three doses per day will suffice.

3 to 4 pills of oxycodone 5 mg per day (ie, 12 tablets) or

3 to 4 pills of hydrocodone 5 mg per day (ie, 12 tablets) (available only with acetaminophen or ibuprofen) (see 'Choice of drug' above) or

3 to 4 pills of hydromorphone 2 mg per day (ie, 12 tablets)

We avoid prescribing tramadol because of wide interpatient variability in metabolism, unreliable analgesia, and related incidences of adverse events. Despite the status of tramadol as a less optimal option, it may be selected if the options listed above are problematic. In such cases, it is usually prescribed as three to four 50 mg pills per day (eg, 12 tablets).

For pain that is expected to last beyond three days, in our practice a five-day prescription (eg, 20 tablets of oxycodone 5 mg or hydromorphone 2 mg) may be reasonable (this is an area of national debate without complete consensus). For older adult or frail patients, lower dose opioid may be sufficient (eg, oxycodone 2.5 mg). (See "Treatment of chronic non-cancer pain in older adults", section on 'Choice and dosing of opioid'.)

Severe pain — Severe pain can be expected after major non-laparoscopic surgery, maxillofacial surgery, total joint replacement, compound fractures, and long bone fracture prior to definitive stabilization. In our experience, a prescription for up to seven days of higher dose opioid may be required to adequately manage pain. If follow-up can be arranged prior to seven days, the prescription should be written for the time period up until the follow-up appointment. This should translate into one of the following prescriptions, for patients without risk factors that require modification of the choice or dose of drug:

4 to 6 pills per day of oxycodone 5 mg or

4 to 6 pills per day of hydrocodone 5 mg (available only with acetaminophen or ibuprofen) (see 'Choice of drug' above) or

4 to 6 pills per day of hydromorphone 2 mg

Patients should be directed to take one tablet no more frequently than every four hours for severe pain.

PATIENT INSTRUCTION — Prior to prescribing an opioid, the clinician should discuss the goals for pain relief, risks and benefits of opioid therapy, other reasonable options for pain management, and specific instructions on taking, stopping, storing, and disposing of medication. Some states mandate that the patient sign a consent prior to starting a long-acting opioid, while others (eg, Vermont) require a signed consent prior to starting any opioid.

Expectation for pain relief — Clinicians should discuss the goals for pain relief with patients, and if appropriate, their care providers, including reasonable expectations for pain relief. The goal should not be zero pain, but mild, tolerable pain that allows the patient to function.

Risks and side effects of opioid therapy — Clinicians should discuss the risks of physiologic dependence, addiction, and overdose, side effects of opioids, and the importance of additional or alternative treatment to reduce the required dose. Discuss the availability of naloxone (see 'Basic strategy for all patients with acute pain' above). An example of patient instructions on prescription opioids is available on the Centers for Disease Control and Prevention (CDC) website [75].

Opioids are associated with nausea and vomiting, dizziness, drowsiness, and a dose-dependent incidence of constipation [76]. For patients who are prone to constipation, older patients, and those who are prescribed more than a few days of opioids, we co-prescribe a laxative and stool softener (table 1).

How to take medication — The patient should receive specific instructions on the way to take opioid and non-opioid medication, including how to decrease or stop the medication. Patients should be informed that opioids should only be used when non-opioid pain medications/treatments fail to provide adequate pain relief, and opioids should be the first medication weaned as pain resolves.

Safe storage and disposal — Opioids should be stored by patients in secure locations and excess pills should be disposed of properly, to minimize the risk of diversion and inappropriate use. Patients should receive specific instruction on both issues. Most studies have reported that patients do not routinely receive instruction on storage and disposal of opioids [26,77], and most keep surplus medication at home for later use [25,27,51].

The US Food and Drug Administration (FDA) has issued guidelines for disposal of opioid medication. When possible, the FDA recommends taking excess opioids to US Drug Enforcement Agency authorized take back locations, which are often pharmacies or police stations. Alternatively, opioids can either be combined with an unpalatable substance (eg, dirt or kitty litter) and placed in a sealed a container in household trash, or flushed down the sink or toilet [78].

Written information for patients — Written information for patients in English and Spanish is available elsewhere in UpToDate. (See "Patient education: Opioid medicines for short-term treatment of pain (The Basics)".)

EXISTING GUIDELINES AND STATE RECOMMENDATIONS — Guidance on opioid prescription for acute pain was included in the 2022 Centers for Disease Control and Prevention (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain [79]. In addition, a number of state governments and agencies, state medical societies, and hospital systems have published guidelines, issued regulations, or passed laws that apply to the management of acute pain, including prescription of opioids. Such guidelines acknowledge that individual patient needs vary, and they typically include best practices for the following aspects of pain management:

Patient evaluation

Monitoring for the risk of opioid use disorder  

Use of prescription drug monitoring programs

The use of multimodal pain control

Avoidance of unnecessary, excessive, or inappropriate opioid prescription

Patient education on the risks of opioid therapy, goals of therapy, and safe storage and disposal of medication  

Legislation and regulation of opioid prescription continue to evolve, and clinicians should be aware of those that are specifically applicable.

PRESCRIPTION DRUG MONITORING PROGRAMS — Partially in response to problems with opioid misuse, all states have instituted prescription drug monitoring programs (PDMPs). Some states require, and others suggest, that clinicians check the PDMP database prior to prescribing opioids. Limited study of the effectiveness of PDMPs has reported mixed results [80]. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Prescription monitoring programs'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Opioid medicines for short-term treatment of pain (The Basics)")

SUMMARY AND RECOMMENDATIONS

Risks of opioid use for acute pain – Opioid use for acute pain is associated with long-term opioid use, and a greater amount of initial opioid exposure (ie, higher total dose) is associated with both greater risk of long-term use, and greater risk of overdose. Thus, opioids should be prescribed only when necessary, in the lowest effective dose, and for the shortest duration required. (See 'Risk of long-term opioid use' above.)

Excessive-prescription of opioids frequently results in leftover pills, which are available for diversion and inappropriate use. (See 'Excessive prescription' above.)

Choice of opioid

Oxycodone 5 mg, hydromorphone 2 mg, and hydrocodone 5 mg, each in combination with acetaminophen or ibuprofen, are equally efficacious when administered for a variety of painful conditions. We avoid the use of codeine and tramadol because of wide interpatient variability in metabolism, and related incidences of adverse events and unreliable analgesia. (See 'Choice of drug' above.)

We recommend prescribing short-acting or immediate-release opioids, rather than long-acting or extended release opioids, for acute pain in opioid naïve patients (Grade 1C). Rapid titration to effect is easier and safer with immediate release opioids, and unintentional overdose may be more likely if opioid therapy is initiated with long-acting opioid. (See 'Short- versus long-acting opioid' above.)

Strategy for all patients – The goal for pain control should be a tolerable level of pain that allows optimal physical and emotional function. The pain control strategy for patients with any degree of acute pain should include the following (see 'Basic strategy for all patients with acute pain' above):

Assessment of the level of pain, analgesic use prior to discharge, and options for follow-up.

Treatment with a multimodal, opioid sparing strategy that includes non-opioid pharmacologic (eg, acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDS]) and nonpharmacologic therapies (eg, ice, rest, immobilization).

If opioids are necessary, the Prescription Drug Monitoring Database should be checked, opioids should be tapered as quickly as possible, and patients should receive specific instructions on the use, discontinuation, storage, and disposal of opioids. Discuss availability of naloxone. (See 'Patient instruction' above.)

Prescription based on the degree of pain – The degree and duration of acute pain may be difficult to predict, and is affected by the type of surgery or injury and patient factors. In general, procedures and injuries that involve bones and joints are more painful than those that involve soft tissues. (See 'Level of pain' above.)

Patients with mild pain – For mild acute pain, opioids should generally not be used. Mild pain should be expected after sprains, nonspecific low back pain, dental extraction, and headache. Treatment should include regularly scheduled acetaminophen and/or NSAIDs, and nonpharmacologic therapy. (See 'Mild pain' above.)

Patients with moderate pain – For moderate pain (eg, after most laparoscopic or minimally invasive surgery, most soft tissue surgery, non-compound and non-comminuted fractures), in most cases a three day course of oxycodone (ie, 12 tablets of oxycodone 5 mg) should provide adequate pain relief. For pain expected to last beyond three days, in appropriate cases, a five day prescription (ie, 20 tablets of oxycodone 5 mg) is reasonable. (See 'Moderate pain' above.)

Patients with severe pain – For severe pain (eg, after discharge from major non-laparoscopic surgery, maxillofacial surgery, total joint replacement, compound fracture, long bone fracture prior to definitive stabilization) prescription of higher dose opioid may be required (eg, 4 to 6 tablets of oxycodone 5 mg per day) for up to seven days, or until follow-up visit at less than seven days. (See 'Severe pain' above.)

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Topic 108806 Version 38.0

References