Framing Opioid Prescribing Guidelines for Acute Pain Developing the Evidence (2020) / Chapter Skim
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2 Managing Acute Pain
2 Managing Acute Pain
Pages 23-44
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From page 23... ...
In 2000, The Joint Commission (2016) issued standards for pain assessment and management practices that imposed criteria for health care organization policies addressing pain that increased the use of patients' self-reported pain to guide pain management.
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From page 24... ...
. Furthermore, suboptimal pain management can contribute to increased morbidity, slow recovery, prolonged opioid use during and after hospitalization, an increased cost of care, and an increased risk of progression to chronic pain (Gan, 2017)
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As noted in the 2017 National Academies of Sciences, Engineering, and Medicine (the National Academies) report Pain Management and the Opioid Epidemic, opioids have long been prescribed for the effective management of acute pain, such as postoperative and postprocedural pain, "and they have been found to be more effective than placebo for nociceptive and neuropathic pain of less than 16 weeks' duration" (Furlan et al., 2011; NASEM, 2017, p.
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From page 26... ...
. An analysis of data from the NHAMCS and the National Ambulatory Medical Care Survey for Adolescents and Young Adults showed that opioid prescribing rates were highest for adolescents and young adults presenting to the ED with dental disorders, followed by clavicle and ankle fractures (Hudgins et al., 2019)
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From page 27... ...
. The 2017 National Academies report Pain Management and the Opioid Epidemic stated: there are some circumstances in which nonopioid analgesics (e.g., nonsteroidal anti-inflammatory drugs)
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From page 28... ...
These factors include • patients who have not had appropriate pain treatment; • patients who are unable to communicate their pain, such as infants or those with cognitive impairments; • patients with chronic pain who are already using opioids and might be opioid-tolerant; • patients in whom the pharmacology of opioids may differ from the typical, such as children or the elderly; • patients for whom the understanding of or adherence to a treatment plan of care may be challenging; • patients who may be at risk for substance use disorder; and • patients who have genomic or other medical factors that may affect their response to opioid treatment. Optimal postoperative pain management requires an understanding of each patient-specific factor.
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From page 29... ...
(new indication, episodic, or pain management Use of other health care exacerbation of chronic condition) providers PROMPT ACCESS REQUIRED FOR Initial and follow-up appointments Pharmacy Nonopioid treatments Health insurance or other financial resources FIGURE 2-1 Clinical factors that influence the decision to prescribe opioids for a patient with acute pain.
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From page 30... ...
The authors of both studies suggest that there is no advantage to weight-based opioid dosing versus fixed opioid dosing for pain response. As such, weight-based dosing is not typically considered in adult opioid dosing; however, extremes in weight should be considered as they may increase the risk for adverse effects, including respiratory depression in patients who are obese (Lloret Linares et al., 2009)
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From page 31... ...
. Both factors have, in turn, increased the number of opioid-tolerant patients, making the treatment of acute and chronic pain more difficult.
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. Other risk factors for opioid misuse include a history of medical use of a prescription opioid (Miech et al., 2015)
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From page 33... ...
For blacks, opioid treatment disparities remained consistent across pain types, settings, study quality, and data collection periods. One study found that black pediatric patients with appendicitis were less likely to receive opioid analgesia for moderate and severe pain than white patients (12.2% versus 33.9%)
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From page 34... ...
Health Care Settings Patients seek and receive treatment for acute pain in diverse health care settings, including hospitals, EDs, primary care offices, urgent care centers, long-term care facilities, pharmacies, and specialty clinics such as pain management, surgery, pediatrics, internal medicine, chiropractic, obstetrics and gynecology, and osteopathy. The health care setting in which pain is treated, including follow-up care, plays an influential role on the clinician's ability and decision to prescribe an opioid after discharge and how to determine the proper dose.
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From page 35... ...
For example, patients undergoing knee arthroplasty with a planned inpatient stay, during which both intravenous and oral opioid regimens are given for postoperative pain control, may experience different pain management than patients undergoing knee arthroplasty as an outpatient procedure, for which postoperative prescribing must anticipate the potential pain a patient might experience at home when intravenous opioids are no longer available (Kelly et al., 2018)
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From page 36... ...
These initiatives have resulted in reducing, but not necessarily eliminating, the need for outpatient opioid prescribing. Prompt Access to Pain Management Interventions After the patient receives his or her treatment recommendations, referrals, and prescriptions, other factors will affect the patient's ability to implement pain management.
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, requiring lengthy travel to fill a prescription. All of these factors can affect a patient's ability to maintain a pain management regime.
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2012. Ethnic differences in pain and pain management.
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2015. Racial disparities in pain management of children with appendicitis in emergency departments.
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2016. Interpreting the National Hospital Ambulatory Medical Care Survey: United States emergency department opioid prescribing, 2006–2010.
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2017. Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use.
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2015. A qualitative study of veterans on long-term opioid analgesics: Barriers and facilitators to multimodality pain management.
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2010. Acute pain management in children.
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