Tips and tools for safe opioid prescribing
This review—with tables summarizing opioid options, dosing considerations, and recommendations for tapering—will help you provide rigorous Tx for noncancer pain while ensuring patient safety.
PRACTICE RECOMMENDATIONS
› Use a screening instrument such as the Opioid Risk Tool or the DIRE assessment to gauge a patient’s risk of opioid misuse and determine the frequency of monitoring. C
› Give as much priority to improving functional activity and minimizing adverse opioid effects as you do to relieving pain. C
› Prescribe an immediate-release, short-acting agent at first instead of a long-acting formulation; start with the lowest effective dosage and calculate total daily dose in terms of morphine milligram equivalents (MME). C
› Reduce the original MME dose by 5% to 10% every week when discontinuing an opioid. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Treatment goals should be established and understood by the prescriber and patient prior to initiation of opioids.28 Overarching treatment goals for all opioids prescribed are pain relief (but not necessarily a focus on pain scores), improvement in functional activity, and minimization of adverse effects, with the latter 2 goals taking precedence.31 To assess outcomes, formally measure progress toward goals from baseline evaluations. This can be achieved through repeated use of validated tools such as those mentioned earlier, or may be more broadly considered as progress toward employment status or increasing participation in activities.31 All pain management plans involving opioids should include continued efforts with nonpharmacologic therapy (eg, exercise therapy, weight loss, behavioral training) and nonopioid pharmacologic therapy (eg, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, anticonvulsants).28
Have an “exit strategy.” As part of goal setting, also consider how therapy will be discontinued if benefits do not outweigh the risks of harm.28 Weigh functional status gains against adverse opioid consequences using the PEG scale (pain, enjoyment of life, and general activity) (TABLE 232).33 Improvements of 30% from baseline have been deemed clinically meaningful by some,32 but not all benefits will be easy to quantify. At the start of treatment dialogue, use the term “therapeutic trial” instead of ”treatment plan” to more effectively convey that opioids will be continued only if safe and effective, and will be prescribed at the lowest effective dose as one component of the multimodal approach to pain.30
Initiation of treatment: Opioid selection and dosing
When initiating opioid therapy, prescribe an immediate-release, short-acting agent instead of an ER/LA formulation.28
For moderate pain, first consider tramadol, codeine, tapentadol, or hydrocodone.31 Second-line agents for moderate pain are hydrocodone or oxycodone.31
For severe pain, first-line agents include hydrocodone, oxycodone, hydromorphone, or morphine.31 Second-line agents for severe pain are fentanyl and, with careful supervision or referral to a pain specialist, methadone or buprenorphine.31
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