New opioid guidelines for acute pain

By Melissa Brewster, PharmD – CareOregon

The State of Oregon recently published guidelines for the treatment of acute pain for patients not currently on opioids. Oregon has focused on reducing opioid use for the treatment of chronic pain for the past several years, but has shifted attention to acute pain prescribing with a new statewide Performance Improvement Plan. The intent is to reduce the day supply of an initial opioid prescription for patients who are opioid naïve.

For most cases of acute pain, NSAIDs and acetaminophen have been shown to be as effective as opioids. Evidence also points to an increased risk of chronic opioid use with increases in the day supply of the first opioid prescription – 40% of patients given an initial opioid prescription of 30 days are still on opioids three years later.

In general, opioids should not be considered first-line therapy for mild to moderate pain in patients with limited past exposure to opioids (i.e., opioid naïve). If other options are not appropriate or effective for acute pain, follow these recommendations before any new opioid prescription:

  • Avoid prescribing opioids without a direct patient-to-prescribing-clinician assessment
  • Assess history of long-term opioid use and/or substance use disorder
  • Check the Prescription Drug Monitoring Program
  • Provide patient education regarding the risks of opioids
  • Prescribe the lowest effective dose of short-acting opioids usually for a duration of less than three days; in cases of more severe acute pain, limit initial prescription to less than seven days.
  • Do not prescribe opioids and benzodiazepines simultaneously unless there is a compelling justification
  • Before providing a refill, re-assess the patient’s pain, level of function, healing process and response to treatment. Explore other non-opioid treatment options. Do not prescribe a refill of opioids without a direct patient to prescribing clinician assessment