II. Precautions

  1. Ask patients if there are prescriptions they should not take or do not want to take before prescribing
    1. Some patients, sober from as Chemical Dependency history, may decline Opioids to prevent relapse
    2. Orman and Starr in Herbert (2018) EM:Rap 18(2):15

III. Management: Patient Education

  1. Opioids can only be expected to reduce acute pain by up to 50%
    1. Primary goal is to improve function
  2. Non-Opioids may be as effective as Opioids
    1. Combination of Ibuprofen 200 mg with Acetaminophen 500 mg
      1. Very effective for post-operative pain without the risks of Opioids
      2. Derry (2013) Cochrane Database Syst Rev (6):CD010210 +PMID:23794268 [PubMed]
  3. Opioids have significant adverse effects including respiratory depression, apnea and death
    1. See Opioid Adverse Effect Management
    2. Prescribe Naloxone for home in case of Overdose for those on high dose Opioids
    3. Avoid combining Opioids with Sedatives (e.g. Benzodiazepines, Muscle relaxants)
    4. Exercise caution in already compromised respiratory status (e.g. COPD, Sleep Apnea)
  4. Opioids are best limited to short periods of acute pain as they have long-term risks of Disability
    1. Limit short-acting Opioid, acute prescriptions to 3-7 day courses
      1. See Opioid Prescribing Quantity
      2. Prescribe the minimum quantity appropriate for the acute condition
    2. Opioids become less effective due to tolerance with continued use
    3. A single Opioid refill increases risk that patient will still be using Opioids in one year (NNH 7)
    4. Even a short course of Opioids (100-150 mg Morphine Equivalent) has significant risk
      1. Doubles risk of longterm Disability from Chronic Pain
      2. Most Chronic Opioid use or misuse starts with acute pain prescriptions
  5. Opioid prescriptions have restrictions
    1. Lost or stolen controlled substances are not replaced
    2. Patients must establish with an outpatient provider for refills of medications
  6. Opioid Dependence is a significant risk
    1. Risk of longterm Opioid Dependence increases significantly in the first three months of use
      1. More than 10% of patients on Opioids for acute pain, continue them chronically
      2. Tolerance and dependence occurs in most patients with longterm use
      3. Recreational Narcotic Abuse (e.g. Heroin use) occurs in 25% of longterm users
      4. Opioid Addiction occurs in 10% of longterm users
      5. Vowles (2015) Pain 156(4): 569-76 [PubMed]
    2. Emergency department Opioid prescriptions account for only 3-5% but can also risk longterm use
      1. Overall, for every 50 ED Opioid prescriptions, one patient will become a longterm user
      2. High intensity Opioid prescribers (24% of patients prescribed Opioids) increase risk of longterm use
        1. Odds Ratio 1.3, compared with low intensity prescribers (7% of patients prescribed Opioids)
      3. Barnett (2017) N Engl J Med 376(7): 663-73 [PubMed]
    3. Tools exist to predict Opioid Dependence risk
      1. DIRE Score
      2. Opioid Risk Tool
    4. Chemical Dependency and maladaptive behaviors can result from misuse or overuse of Opioid Analgesics
      1. Drug diversion
      2. Narcotic Seeking Behavior
      3. Narcotic Addiction

IV. References

  1. Hipskind and Kamboj (2016) Crit Dec Emerg Med 30(10): 15-23
  2. Dowell (2022) MMWR Recomm Rep 71(3):1-95 +PMID: 36327391 [PubMed]

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