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Acute pain (<1-mo duration)
Determine whether or not to initiate opioids for acute pain - Non-opioid therapies at least as effective as opioids for many common types of acute pain [B/3]
- Maximize use of nonpharmacologic (eg, ice, heat, elevation, rest, immobilization, exercise) and non-opioid drug therapies (eg, topical or PO NSAIDs, acetaminophen) as appropriate for specific condition and pt [B/3]
- Only consider opioid tx for acute pain if benefits anticipated to outweigh risks to pt [B/3]
- Before prescribing opioid tx, discuss w/ pt the realistic benefits and known risks of opioid tx [B/3]
- Practice points
- Prescribing outpt opioid tx for acute pain: Discussion points
Select opioids and determine opioid dosages - When starting opioid tx for acute pain, prescribe IR opioids instead of ER/LA opioids [A/4]. Practice points
- When initiating opioids for opioid-naïve patients w/ acute pain, prescribe the lowest effective dosage [A/3]. Practice points
- For pts already receiving opioid tx, carefully weigh benefits and risks and exercise care when changing opioid dosage [B/4]
- If benefits outweigh risks of continued opioid tx, work closely w/ pts to optimize non-opioid therapies while continuing opioid tx [B/4]
- If benefits don’t outweigh risks of continued opioid tx, optimize other therapies and work closely w/ pts to gradually taper to lower dosages or, if warranted, appropriately taper and D/C opioids [B/4]
- Unless there’s a life-threatening issue such as signs of impending OD (eg, confusion, sedation, or slurred speech), don’t D/C opioid tx abruptly, and avoid rapid dose reductions from higher doses [B/4]
- Practice points
Decide on duration of initial opioid Rx and F/U - When opioids are needed for acute pain, prescribe no greater quantity than needed for expected duration of pain severe enough to require opioids [A/4]. Practice points
Assess risk and address potential harms of opioid use - Before starting and periodically during continuation of opioid tx, evaluate risk for opioid-related harms and discuss risk w/ pts. Work w/ pts to incorporate risk mitigation strategies into mgmt plan, incl offering naloxone [A/4]. Practice points
- When prescribing initial opioid therapy for acute pain, review pt’s hx of controlled substance prescriptions using state PDMP data to determine whether the pt is receiving opioid dosages or combos that put the pt at high risk for OD [B/4]. Practice points
- Use caution when prescribing opioid pain med and BZD concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other CNS depressants [B/3]. Practice points
- Offer/arrange treatment w/ evidence-based meds to treat pts w/ OUD. Detoxification alone, w/o meds for OUD, isn’t recommended for OUD because of increased risks for resuming drug use, OD, and OD death [A/1]. Practice points
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Subacute pain (1-3-mo duration)
Determine whether or not to initiate opioids for subacute pain
- Non-opioid therapies are preferred for subacute pain [A/2]
- Maximize use of nonpharmacologic and non-opioid pharmacologic therapies as appropriate for the specific condition and pt; only consider initiating opioid tx if expected benefits for pain and function are anticipated to outweigh pt risks [A/2]
- Before starting opioid tx for subacute pain, discuss w/ pts the realistic benefits and known risks of opioid tx. Work w/ pts to establish tx goals for pain and function; consider how opioid tx will be discontinued if benefits don’t outweigh risks [A/2]
- Practice points
- Prescribing outpt opioid tx for subacute or chronic pain: Discussion points
Select opioids and determine opioid dosages - When starting opioid tx for subacute pain, prescribe IR opioids instead of ER/LA opioids [A/4]. Practice points
- When opioids are initiated for opioid-naïve pts w/ subacute pain, prescribe the lowest effective dosage [A/3]
- If opioids are continued for subacute pain, use caution when prescribing opioids at any dosage, carefully evaluate individual benefits and risks when considering increasing dosage, and avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to pts [A/3]. Practice points
- For patients already receiving opioid tx, carefully weigh benefits and risks and exercise care when changing opioid dosage [B/4]
- If benefits outweigh risks of continued opioid tx, work closely w/ pts to optimize non-opioid therapies while continuing opioid tx [B/4]
- If benefits don’t outweigh risks of continued opioid tx, optimize other therapies and work closely w/ pts to gradually taper to lower dosages or, if warranted, appropriately taper and D/C opioids [B/4]
- Unless there’s a life-threatening issue such as signs of impending OD (eg, confusion, sedation, or slurred speech), don’t D/C opioid tx abruptly, and avoid reduce opioid dosages from higher doses [B/4]
- Practice points
Decide on duration of initial opioid Rx and F/U - Evaluate benefits and risks w/ pts w/in 1–4wk of starting opioid tx for subacute pain or of dosage escalation. Regularly reevaluate benefits and risks of continued opioid tx w/ pts [A/4]. Practice points
Assess risk and address potential harms of opioid use - Before starting and periodically during continuation of opioid tx, evaluate risk for opioid-related harms and discuss risk w/ pts. Work w/ pts to incorporate risk mitigation strategies into the mgmt plan, incl offering naloxone [A/4]. Practice points
- When prescribing initial opioid tx for subacute pain, review the pt’s hx of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the pt is receiving opioid dosages or combos that put the pt at high risk for OD [B/4]. Practice points
- When prescribing opioids for subacute pain, consider the benefits and risks of toxicology testing to assess for prescribed meds as well as other prescribed and nonprescribed controlled substances [B/4]. Practice points
- Use caution when prescribing opioid pain meds and BZDs concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other CNS depressants [B/3]. Practice points
- Offer/arrange treatment w/ evidence-based meds to treat pts w/ OUD. Detoxification alone, w/o meds for OUD, isn’t recommended for OUD because of increased risks for resuming drug use, OD, and OD death [A/1]. Practice points
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Chronic pain (>3-mo duration)
Determine whether or not to initiate opioids for chronic pain - Non-opioid therapies are preferred for chronic pain [A/2]
- Maximize use of nonpharmacologic and non-opioid pharmacologic therapies as appropriate for the specific condition and pt; only consider initiating opioid tx if expected benefits for pain and function are anticipated to outweigh pt risks [A/2]
- Before starting opioid tx for chronic pain, discuss w/ pts the realistic benefits and known risks of opioid tx. Work w/ pts to establish tx goals for pain and function; consider how opioid tx will be discontinued if benefits don’t outweigh risks [A/2]
- Practice points
- Prescribing outpt opioid tx for subacute or chronic pain: Discussion points
Select opioids and determine opioid dosages - When starting opioid tx for chronic pain, prescribe IR opioids instead of ER/LA opioids [A/4]. Practice points
- When opioids are initiated for opioid-naïve pts w/ chronic pain, prescribe the lowest effective dosage [A/3]
- If opioids are continued for chronic pain, use caution when prescribing opioids at any dosage, carefully evaluate individual benefits and risks when considering increasing dosage, and avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to pts [A/3]. Practice points
- For patients already receiving opioid tx, carefully weigh benefits and risks and exercise care when changing opioid dosage [B/4]
- If benefits outweigh risks of continued opioid tx, work closely w/ pts to optimize non-opioid therapies while continuing opioid tx [B/4]
- If benefits don’t outweigh risks of continued opioid tx, optimize other therapies and work closely w/ pts to gradually taper to lower dosages or, if warranted, appropriately taper and D/C opioids [B/4]
- Unless there’s a life-threatening issue such as signs of impending OD (eg, confusion, sedation, or slurred speech), don’t D/C opioid tx abruptly, and avoid reduce opioid dosages from higher doses [B/4]
- Practice points
Decide on duration of initial opioid Rx and F/U - Evaluate benefits and risks w/ pts w/in 1–4wk of starting opioid tx for chronic pain or of dosage escalation. Regularly reevaluate benefits and risks of continued opioid tx w/ pts [A/4]. Practice points
Assess risk and address potential harms of opioid use - Before starting and periodically during continuation of opioid tx, evaluate risk for opioid-related harms and discuss risk w/ pts. Work w/ pts to incorporate risk mitigation strategies into the mgmt plan, incl offering naloxone [A/4]. Practice points
- When prescribing initial opioid tx for chronic pain, review the pt’s hx of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the pt is receiving opioid dosages or combos that put the pt at high risk for OD [B/4]. Practice points
- When prescribing opioids for chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed meds as well as other prescribed and nonprescribed controlled substances [B/4]. Practice points
- Use caution when prescribing opioid pain meds and BZDs concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other CNS depressants [B/3]. Practice points
- Offer/arrange treatment w/ evidence-based meds to treat pts w/ OUD. Detoxification alone, w/o meds for OUD, isn’t recommended for OUD because of increased risks for resuming drug use, OD, and OD death [A/1]. Practice points
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