CME credit available from Massachusetts Medical Society through March 2018.
Managing pain without overusing opioids
This educational program focuses on the management of both acute and chronic non-cancer pain and provides evidence for non-pharmacologic and pharmacologic treatment alternatives.
The use of prescription opioids in the US has risen rapidly and actually quadrupled between 1999 and 2010.1 While opioid analgesics are widely prescribed for chronic non-cancer conditions,2 the evidence base supporting such a vastly expanded use is limited.3 As opioid prescriptions have risen, so, too have rates of opioid abuse, addiction, and diversion, to their current ‘epidemic’ levels.1
Figure 1. Opioid pain medication use increased sharply, as did deaths caused by prescription pain medications and admissions for the treatment and abuse of these products.1
Acute pain: limit quantities and educate patients
Patients frequently receive opioids either for acute pain or after an operation. However, these patients often do not take all of the opioid pills prescribed.4 These left over pills are kept by the majority of patients, leading to availability of opioids for non-medical use in the home.5 Prescribing shorter courses of opioids for acute pain and counseling patients to safely store and properly dispose of unneeded opioid prescriptions can help reduce the potential for misuse and abuse.
Figure 2. In a recent study of patients prescribed opioids after outpatient orthopedic surgery, almost half of patients used less than 5 pills from the average of 30 dispensed.4
Optimize non-opioid treatment options
The management of chronic pain focuses on achieving functional goals. A multifaceted approach combines both non-pharmacologic and non-opioid pharmacologic treatment options. Non-pharmacologic interventions include exercise, weight training, yoga, relaxation and many other options. In newly diagnosed chronic pain patients, optimize multiple non-opioid medications before considering opioids.
Opioids: little proven efficacy, considerable harm
While opioids may reduce pain in the short term, there is currently no evidence to support their long-term use in the management of chronic pain. Trials examining efficacy are short, with a mean duration of five weeks.6
The risks associated with prescription opioids are well documented, including:
- misuse, abuse, addiction
- chronic constipation
- intention or accidental overdose
- falls and fractures
- low testosterone
These risks escalate with increasing doses. Doses in excess of 100mg of morphine equivalents per day are associated with the greatest risks of opioid complications.
Screening and monitoring
When the decision is made to initiate an opioid, screen patients for risk factors, including abuse and vulnerability to potential side effects.7
Figure 3: Use a tool like ABCDPQRS to assess opioid risk
Implement a monitoring strategy reviewing activity, analgesia, adverse effects and abuse. Incorporate a review of the prescription drug monitoring program into chronic pain visits.
For patients who have adverse effects or are not achieving their functional goals on opioids, taper and discontinue opioid treatment.
- Centers for Disease Control & Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR. Morbidity and mortality weekly report. 2011;60(43):1487-1492.
- Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
- Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011;155(5):325-328.
- Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. The Journal of hand surgery. 2012;37(4):645-650.
- Centers for Disease C, Prevention. Adult use of prescription opioid pain medications – Utah, 2008. MMWR. Morbidity and mortality weekly report. 2010;59(6):153-157.
- Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11):1589-1594.
- Thorson D, Biewen P, Bonte B, Epstein H, Haake B, Hansen C, Hooten M, Hora J, Johnson C, Keeling F, Kokayeff A, Krebs E, Myers C, Nelson B, Noonan MP, Reznikoff C, Thiel M, Trujillo A, Van Pelt S, Wainio J. Institute for Clinical Systems Improvement. Acute Pain Assessment and Opioid Prescribing Protocol. Published January 2014.