New Opioid Prescribing Guidance Targets Inpatient Acute Pain Management

In a new guidance on safe opioid prescribing issued by a national working group, health care providers are urged to restrict opioid use for hospitalized adults with acute pain and consider the benefits and risks when determining the best treatment option for patients in an inpatient setting.

The set of 16 recommendations, published in the Journal of Hospital Medicine, provides guidance on when to use opioids versus other pain management methods in the inpatient, non-operative setting.

According to the recommendations, health care professionals should limit the use of opioids to cases of severe or moderate pain only in patients who do not respond to or cannot take non-opioid pain medication, such as acetaminophen or ibuprofen.

“Clinicians tend to underestimate the benefit of non-opioid analgesics and overestimate the risks, while for opioids they overestimate the benefits and underestimate the risks,” Shoshana J Herzig, MD, MPH, lead study author, said in a press release. “For most painful conditions, acetaminophen and non-steroidal anti-inflammatory drugs have been shown to be equally or more effective with less risk of harm than opioids.”

The recommendations were developed as part of a nationwide working group convened by the Society of Hospital Medicine, a professional organization representing more than 57,000 hospitalists. Researchers developed the guidance following a systematic review of approximately 1000 relevant opioid-prescribing guidelines. The researchers excluded studies published prior to 2010, those focused on chronic pain, palliative care or specific medical conditions, or those relevant to intensive care units and non-hospital settings.

Of the remaining 4 guidelines reviewed, all of them recommended prescribing a limited duration of opioids for acute pain episodes, with US-based guidelines recommending 1 to 2 weeks as the maximum duration of opioid use, including the period of hospitalization. Most guidelines overlapped in terms of recommendations related to safe prescribing, according to the review.

However, there was less consensus on risk mitigation strategies. Several strategies were identified, but most were only recommended by a single guideline, the researchers noted. Strategies recommended by more than 1 guideline included using a recognized opioid dose conversion guide when prescribing, reviewing, or changing opioid prescriptions and avoiding co-administration of parenteral and oral as-needed opioids. If as-needed opioids from different routes are necessary, providers should give a clear indication for use of each and avoid/use caution when co-prescribing opioids with other central nervous system depressant medications.

Health care providers should consider the risk-to-benefit ratio of opioid and non-opioid therapy when determining initial pain management strategy, Dr Herzig noted. This guidance is intended to help clinicians balance the benefits of opioid treatment against the risks in the inpatient setting.

For patients who do receive opioid treatment, the guidance recommends prescribing the lowest effective doses for the shortest duration possible, as well as using immediate-release opioid formulations and giving the drugs orally when possible.

Additionally, the recommendations emphasize educating patients, families, and caregivers about opioids and patients’ expected course of recovery. According to the guidance, providers should inform patients that non-opioid pain management alternatives are available and may control pain equally, as well as help patients understand that successful opioid therapy not only reduces pain but also improves function.

“Although most recommendations are based exclusively on expert opinion, our systematic review nonetheless represents the best guidance currently available,” Dr Herzig said in the press release. “Additional research will be necessary to understand the risk factors in hospitalized medical patients and to inform evidence-based, safe prescribing recommendations in this setting.”

Reference

Herzig SJ, Calcaterra SL, Mosher HJ, et al. Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines. J Hosp Med. April 2018. https://www.journalofhospitalmedicine.com/jhospmed/article/161929/hospital-medicine/safe-opioid-prescribing-acute-noncancer-pain-hospitalized.

Working Group Offers New Guidance for Safe Opioid Prescribing for Hospitalized Patients with Acute Pain [news release]. Boston. BIDMC’s website. https://www.bidmc.org/about-bidmc/news/working-group-offers-new-guidance-for-safe-opioid-prescribing-for-patients-with-acute-pain. Accessed April 9, 2018.