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Opioids

Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department (June 2012)

Scope of Application

This guideline is intended for physicians working in hospital-based EDs.

Inclusion Criteria

This guideline is intended for adult patients presenting to the ED with acute noncancer pain or an acute exacerbation of chronic noncancer pain.

Exclusion Criteria

This guideline is not intended to address the long-term care of patients with cancer or chronic noncancer pain.

Critical Questions

  • In the adult ED patient with noncancer pain for whom opioid prescriptions are considered, what is the utility of state prescription drug monitoring programs in identifying patients who are at high risk for opioid abuse?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    The use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shopping.

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    The use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shopping.

  • In the adult ED patient with acute low back pain, are prescriptions for opioids more effective during the acute phase than other medications?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    (1) For the patient being discharged from the ED with acute low back pain, the emergency physician should ascertain whether nonopioid analgesics and nonpharmacologic therapies will be adequate for initial pain management. (2) Given a lack of demonstrated evidence of superior efficacy of either opioid or nonopioid analgesics and the individual and community risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics rather than routinely prescribed. (3) If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (eg,

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    (1) For the patient being discharged from the ED with acute low back pain, the emergency physician should ascertain whether nonopioid analgesics and nonpharmacologic therapies will be adequate for initial pain management. (2) Given a lack of demonstrated evidence of superior efficacy of either opioid or nonopioid analgesics and the individual and community risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics rather than routinely prescribed. (3) If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (eg,

  • In the adult ED patient for whom opioid prescription is considered appropriate for treatment of new-onset acute pain, are short-acting schedule II opioids more effective than short-acting schedule III opioids?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    For the short-term relief of acute musculoskeletal pain, emergency physicians may prescribe short-acting opioids such as oxycodone or hydrocodone products while considering the benefits and risks for the individual patient.
    Level C Recommendations
    Research evidence to support superior pain relief for short-acting schedule II over schedule III opioids is inadequate.
    Level A Recommendations
    None specified.
    Level B Recommendations
    For the short-term relief of acute musculoskeletal pain, emergency physicians may prescribe short-acting opioids such as oxycodone or hydrocodone products while considering the benefits and risks for the individual patient.
    Level C Recommendations
    Research evidence to support superior pain relief for short-acting schedule II over schedule III opioids is inadequate.
  • In the adult ED patient with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing opioids on discharge from the ED outweigh the potential harms?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) Physicians should avoid the routine prescribing of outpatient opioids for a patient with an acute exacerbation of chronic noncancer pain seen in the ED. (2) If opioids are prescribed on discharge, the prescription should be for the lowest practical dose for a limited duration (eg, <1 week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion. (3) the clinician should, if practicable, honor existing patient-physician pain contracts treatment agreements and consider past prescription patterns from information sources such as prescription drug monitoring programs.>
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) Physicians should avoid the routine prescribing of outpatient opioids for a patient with an acute exacerbation of chronic noncancer pain seen in the ED. (2) If opioids are prescribed on discharge, the prescription should be for the lowest practical dose for a limited duration (eg, <1 week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion. (3) the clinician should, if practicable, honor existing patient-physician pain contracts treatment agreements and consider past prescription patterns from information sources such as prescription drug monitoring programs.>

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PDF Icon Opioids 2012.pdf April 2018

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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