Framing Opioid Prescribing Guidelines for Acute Pain Developing the Evidence (2020) / Chapter Skim
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6 Evaluating Clinical Practice Guidelines for Prescribing Opioids for Acute Pain
6 Evaluating Clinical Practice Guidelines for Prescribing Opioids for Acute Pain
Pages 131-166
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From page 131... ...
The analytic framework is for opioid prescribing strategies only and is based on the assumption that a clinician has already determined that opioids are needed for acute pain management. However, this framework does not exclude the consideration and use of nonopioid options, both pharmacologic and nonpharmacologic, with or without opioid analgesics.
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From page 132... ...
These indications were Patient presents with indication OPIOID HEALTH PRESCRIBED INTERMEDIATE OUTCOMES OUTCOMES EVIDENCE EVIDENCE Clinician: • Reviews patient complaint and medical history • Determines acute pain management Intermediate outcomes: Patient and approach population health amount of opioid used/unused, refill outcomes: Opioid Long-term requests, opioid • Pain Opioid prescribing EVIDENCE opioid use Nonopioid misuse, diversion, • Function strategy health costs, patterns of health care • Quality of life utilization • Work or school Nonopioid and/or • Mortality/morbidity nonpharmacologic intervention • Adverse effects FIGURE 6-1 The committee's analytic framework for opioid prescribing in the context of a comprehensive acute pain management plan (left side of figure)
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From page 133... ...
Opioid Prescribing Guidelines Although there is no evidence-based guidance that is labeled as a CPG and addresses opioid prescribing after vaginal or cesarean delivery, the American College of Obstetricians and Gynecologists' (ACOG's) Committee Opinion on Postpartum Pain Management makes a number of recommendations on the use of acetaminophen and NSAIDs, reserving opioid use for breakthrough pain (ACOG, 2018)
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From page 134... ...
. Considerations regarding opioid prescribing for other pre-existing or comorbid conditions are not discussed, although the ACOG committee recognizes that the range of health and socioeconomic statuses among women who give birth may require opioid prescribing be modified to address an individual's physical and mental health, comorbidities, and home environment.
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From page 135... ...
Opioid Prescribing Strategies The 2018 ACOG committee opinion paper states that if analgesics are insufficient for pain management following a vaginal birth, then milder short-acting opioids in combination with acetaminophen may be an effective second step for pain control while the woman is in the hospital (ACOG, 2018)
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From page 136... ...
ACOG emphasizes that therapy should be individualized to each patient. The committee notes that both short- and long-term health outcomes are concerns following discharge opioid prescribing.
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From page 137... ...
Further information on opioid refills obtained outside the delivery hospital system and long-term outcomes would also be useful. Third Molar Extraction Opioid prescriptions for acute pain management after third molar extractions represent a significant proportion of opioid prescribing by dentists.
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From page 138... ...
The AAOMS white paper Opioid Prescribing: Acute and Postoperative Pain Management has a similar recommendation regarding NSAIDs as a "first-line analgesic therapy" and also states, "When indicated for acute breakthrough pain, consider short-acting opioid analgesics. If opioid analgesics are considered, start with the lowest possible effective dose and the shortest duration possible" (AAOMS, 2017)
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From page 139... ...
Intermediate Outcomes Neither the ADA Policy on Opioid Prescribing nor the ADA Statement on the Use of Opioids in the Treatment of Dental Pain provides information on any intermediate outcomes associated with opioid prescribing, such as the amount of opioids used for acute pain management.
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From page 140... ...
The committee notes that one limitation to studies that use these data is that not all patients who have third molar extractions are represented because some patients may not have insurance that covers the procedure. Health Outcomes Neither the ADA Policy on Opioid Prescribing nor the ADA Statement on the Use of Opioids in the Treatment of Dental Pain provides information on any health outcomes associated with opioid prescribing for acute pain following third molar extraction.
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From page 141... ...
Opioid Prescribing Guidelines In 2015 the American Academy of Orthopaedic Surgeons (AAOS) published Surgical Management of Osteoarthritis of the Knee: Evidence-Based Clinical Practice Guideline, which was endorsed by several professional societies, including the American Association of Hip and Knee Surgeons.
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From page 142... ...
. The information statement recommends the following strategies for ensuring safe opioid prescribing: • Establish ranges for acceptable amounts and durations of opioids to treat postprocedural pain, tailored to the intensity of the procedure (small, moderate, and large procedures)
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From page 143... ...
The AAOS CPG does not specifically address opioid prescribing following TKA, although it does consider opioid use and pain control as outcomes by which other best practices should be examined. Although enhancing pain control and reducing opioid use are identified as optimal outcomes, the best practices in opioid prescribing are not described (e.g., use, dosing, and timing of opioid alternatives alongside opioid analgesics and the identification of patients at risk for poor pain- and opioid-related outcomes)
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From page 144... ...
This suggests that a collaborative effort to develop guidelines for opioid prescribing after TKA that includes input from these other prescribers would enhance the reach and impact of such a guideline and improve prescribing practices. APPLYING THE ANALYTIC FRAMEWORK TO SELECTED MEDICAL INDICATIONS The acute pain associated with surgical procedures is usually assumed to be time limited as the patient recovers from the surgery or procedure.
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From page 145... ...
Preventing acute pain from becoming chronic is an important consideration in pain management. The committee chose four medical indications that are known to have acute pain episodes with which to assess its analytic framework for opioid prescribing: renal stones, migraine headache, low back pain, and sickle cell disease.
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From page 146... ...
Thus, the committee did not consider the EAU guidelines to be appropriate for assessing its framework for opioid prescribing for acute pain from renal stones. A systematic review of studies on the prevention of renal stones in adults was performed for the American College of Physicians CPG, but it does not deal with treatment of pain caused by renal stones (Fink et al., 2013)
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From page 147... ...
. Opioid Prescribing Strategies The AUA evidence-based guidelines for the medical management of renal stones (Perle et al., 2014)
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From page 148... ...
Intermediate Outcomes The AUA evidence-based guidelines for the medical management of renal stones (Perle et al., 2014) do not address intermediate outcomes that may be associated with prescribing opioids for acute pain management.
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From page 149... ...
. Opioid Prescribing Guidelines Guidelines and supporting documentation for the pharmacological management of acute migraines have been published and updated by the American Headache Society (AHS)
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From page 150... ...
received three or more opioid prescriptions during the study's observation period. The Practice Guideline Update Summary: Acute Treatment of Migraine in Children and Adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society (Oskoui et al., 2019)
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From page 151... ...
. The recommended adult prescribing strategies in Silberstein (2000)
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From page 152... ...
Given its frequency and impact, the management of low back pain has been the subject of extensive research, systematic reviews, and CPGs. Opioid Prescribing Guidelines Numerous organizations have developed guidance documents for the management of low back pain.
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From page 153... ...
If pharmacologic interventions are used, the ACP CPG recommends NSAIDs or skeletal muscle relaxants, based on moderate-quality evidence indicating improved function and pain versus placebo. Opioid Prescribing Strategies The ACP CPG concluded that there is insufficient evidence to determine the effect of opioids versus placebos for acute low back pain.
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From page 154... ...
Therefore, the ACP CPG does not list opioids as a recommended pharmacologic treatment for acute low back pain, and opioid prescribing strategies in persons with acute low back pain are not addressed. The ACP CPG recommends that opioids only be considered as a treatment option in patients who fail first-line therapies such as NSAIDs, duloxetine, or tramadol, and in patients for whom benefits are likely to outweigh risks.
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From page 155... ...
However, these studies were carried out before the peak of opioid morbidity and mortality in the United States and before the appreciation of serious public health risks linked to excessive opioid prescribing by clinicians. The ACP evidence review concluded that there is moderate evidence from a well-designed RCT that nonpharmacologic treatments are as effective for acute low back pain as opioids.
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From page 156... ...
Acute SCD pain occurs more frequently than chronic SCD pain. Opioid Prescribing Guidelines CPGs have been developed to treat pain associated with SCD.
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From page 157... ...
Antihistamines may also be used to treat itching secondary to opioid administration in the acute VOC management phase. Opioid Prescribing Strategies The NHBLI CPG (2014)
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From page 158... ...
Intermediate Outcomes Because acute pain in SCD is typically episodic and recurrent, the committee recognizes that it may be difficult to apply the analytic framework and assess the impact of different opioid prescribing strategies on long-term health outcomes. However, it may be possible to assess the effect of different prescribing strategies on intermediate outcomes such as the number of refills requested and the number of pills used and unused.
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From page 159... ...
2017. Opioid prescribing: Acute and postoperative pain management.
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From page 160... ...
2018a. Opioid prescribing patterns among postpartum women.
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From page 161... ...
2010. The course of opioid prescribing for a new episode of disabling low back pain: Opioid features and dose escalation.
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From page 162... ...
2016. Interpreting the National Hospital Ambulatory Medical Care Survey: United States emergency department opioid prescribing, 2006–2010.
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From page 163... ...
2016. Dental opioid prescribing and multiple opioid prescriptions among dental patients: Administrative data from the South Carolina prescription drug monitoring program.
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From page 164... ...
2018. Implementation of a quality improvement initiative to decrease opioid prescribing after cesarean delivery.
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From page 165... ...
2009. Geographic variation in opioid prescribing for acute, work-related, low back pain and associated factors: A multilevel analysis.
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