The acute phase of pain is one to four days after a severe injury or a severe medical condition and up to seven days following a major surgical procedure or trauma.
Use caution when prescribing opioids even in this timeframe, given the potential for patients to experience harm related to any new opioid prescription. Avoid using opioids to treat pain in the acute phase unless the severity of the pain warrants the use of opioid analgesia and non-opioid alternatives are ineffective or contraindicated.
The acute phase of pain is one to four days after a severe injury or a severe medical condition and up to seven days following a major surgical procedure or trauma. The first-line pharmacologic therapy for mild to moderate acute nociceptive pain is acetaminophen or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen. Multiple guidelines recommend these two drugs as first-line pharmacologic therapy for pain, however acute pain characteristics and patient risk factors must be considered when prescribing either medication. Acetaminophen should be avoided in patients with liver failure, and dosage should be reduced in patients with hepatic insufficiency or a history of alcohol abuse (FDA, 2015; Guggenheim, 2011). Monitor patients receiving NSAIDS carefully due to the risk of cardiovascular, gastrointestinal, and renal adverse effects (CDC, 2016).
Use caution when prescribing opioids for acute pain, given the potential for patients to experience harm related to any new opioid prescription. A growing body of evidence supports the association between opioid therapy for acute pain and long-term opioid use. A retrospective, observational study examined the probability of long-term use based on a number of characteristics of the initial opioid prescription. The study found that the largest increments in probability of continued opioid use were observed after the fifth and 31st days on therapy; the second prescription; 700 morphine milligram equivalents (MME) cumulative dose; and first prescriptions with 10- and 30-day supplies (Shah, 2017). Acute pain can often be managed without opioid therapy. Clinicians should avoid using opioids to treat pain in the acute phase unless the severity of the pain warrants the use of opioid analgesia and non-opioid alternatives are ineffective or contraindicated.
Clinicians must employ effective risk management in order to prevent overdose, misuse and diversion when considering prescribing opioids during the acute phase. Opioids have a wide range of adverse effects that can predispose a patient to serious morbidity and mortality. This includes respiratory depression (Koo, 2011), negative impact on endocrine function (Vuong, 2010), immunosuppression (Vallejo, 2004), opioid-induced hyperalgesia (Ballantyne, 2007) and possibly heightened fracture risk related to falls (Saunders, 2010).
It is the opinion of the OPWG that all prescribers of opioid analgesia for acute pain should be aware of the patient’s risk factors for opioid-related harm. It is not recommended that formal risk assessments occur in every instance of acute pain in every setting. Yet, prescribers should be aware of the patient’s major risk factors. The Institute for Clinical Systems Improvement Acute Pain Assessment and Opioid Prescribing Protocol work group developed a helpful mnemonic for screening for potential contraindications to opioid use. The
ABCDPQRS mnemonic is one useful tool that addresses potential contraindications/risks to opioid use.
A – Alcohol use
B – Benzodiazepines and other drug use
C – Clearance and metabolism of drug
D – Delirium, dementia and falls risk
P – Psychiatric comorbidities
Q – Query the Prescription Monitoring Program
R – Respiratory insufficiency and sleep apnea
S – Safe driving, work, storage and disposal
Please see Appendix A of the Institute for Clinical Systems Improvement Pain Health Care Guideline (2017) for more detailed information.
A number of opioid prescribing guidelines have included dosage and duration recommendations for acute pain (CDC, 2016a, ICSI, 2017). In addition, several states have passed opioid prescribing limits for acute pain. A majority of the recommendations and the state limits acknowledge that 3 to 7 days of opioid therapy for severe, acute pain is sufficient. The work group concurred with these recommendations, noting that the lowest effective dose and duration is necessary given the risks related to opioid exposure at any amount.
In most cases, pain from surgical procedures—especially outpatient procedures—can be managed effectively without opioids or with up to 100 MME total supply of low-dose, short-acting opioids. However some surgical procedures and traumatic injuries require greater pain management, because of an expectation of increased tissue damage and subsequent inflammatory response. This may include, but is not limited to, procedures and injuries that require more than a 48-hour hospital stay. Experts agreed that up to 200 MME total is an appropriate opioid dose for prescribing in the 7 days post-surgery for most surgical procedures.
The MN Health Collaborative is a partnership between major Minnesota health care organizations and the Institute for Clinical Systems Improvement. The collaborative developed procedure-specific, patient-centric postoperative opioid prescribing recommendations to help prevent under- or over-prescribing of opioids. The MN Collaborative Call to Action: Adult Opioid Postoperative Prescribing report was released in October 2018 and will be updated periodically.
Patients presenting with acute oral or facial pain require adequate pain management.
If a patient presents in pain in a medical facility or hospital with no dentist available, the treating provider should use an appropriate non-opioid medication for pain management prior to diagnosis and treatment for the underlying source of pain.
Non-dental providers should not prescribe an opioid without examination and diagnosis of the underlying reasons for the oral or facial pain.
Opioids can mask pain and allow the patient to ignore an underlying serious dental problem, such as an abscess. Diagnosis should include appropriate tests and x-rays. Refer the patient to a dental provider and assist with access to follow-up when possible.
Prescribing opioid analgesia for acute pain requires additional consideration when the patient is on chronic opioid analgesic therapy (COAT), has a history of substance use disorder or an active substance use disorder. Providers should treat patients with extreme caution, appropriately balancing the need to relieve severe acute pain caused by an injury or surgical procedure and the need to prevent opioid-related harm. It is the expert opinion of the work group that individuals with acute pain generated by an objectively identifiable injury should be treated under the same dosage and duration guidelines. Greater caution should be employed when the patient does not have an objectively, identifiable new injury and providers should treat pain with non-opioid and non-pharmacologic therapies.
Effective management of acute, postoperative pain in opioid-tolerant patients may require additional education and resources. It is important to effectively manage acute, postoperative pain and opioid-tolerant patients should receive no less treatment than opioid-naïve patients. For opioid-tolerant patents taking up to 90 MME/day, the standard postoperative dose and duration recommendations apply. Postoperative pain management for patients taking over 90 MME/day should involve the prescriber of chronic opioid therapy, pain specialists, anesthesiology and psychologists.