Framing Opioid Prescribing Guidelines for Acute Pain Developing the Evidence (2020) / Chapter Skim
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5 Identifying and Prioritizing Indications for Clinical Practice Guidelines
5 Identifying and Prioritizing Indications for Clinical Practice Guidelines
Pages 85-130
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From page 85... ...
committee was tasked with identifying and prioritizing up to 50 specific surgical procedures and medical conditions that are associated with acute pain and for which opioid analgesics are commonly prescribed. The committee was also tasked with recommending where evidence-based CPGs would help inform prescribing practices.
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From page 86... ...
For example, several CPGs broadly address both acute and chronic pain, but are not specific for a particular surgical or medical indication. These include the American Society of Interventional Pain BOX 5-1 Key Factors for the Prioritization of Indications for Clinical Practice Guideline Development • Prevalence of the surgical procedure or medical indication; • Variation in opioid prescribing across providers; • Variation in opioid prescribing in relation to patient-centered or patient-reported outcomes; and • Availability of an evidence-based CPG that describes opioid prescribing for acute pain associated with the indication.
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From page 87... ...
The committee emphasizes that because of substantial variation in the presentation of acute pain, the list of priority indications developed by the committee in Tables 5-2 and 5-3 should not be considered to be as exclusive or exhaustive. There are other factors that may influence the inclusion of a condition for CPG development, including opioid prescribing practices, strong stakeholder advocacy, the probability of converting acute to chronic pain, and expert judgment.
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From page 88... ...
Because procedures are performed by defined groups or specialties, health care organizations have the opportunity to track pain- and opioid-related outcomes as well as opioid prescribing in order to create best practices, identify outliers, and enhance the safety and quality of postoperative pain management. The committee notes that it found more evidence of variation in opioid prescribing and discrepancies in opioid prescribing, opioid consumption, and pain-related outcomes for surgical procedures than for medical conditions causing acute pain (see Tables 5-2 and 5-3)
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From page 89... ...
. A recent study of pediatric patients undergoing outpatient surgery found that after the implementation of institutional guidelines, most patients were not prescribed opioids following surgery, did not report opioid use, did not require refills, and that a greater proportion of patients were directed to and used nonopioid alternatives for postoperative pain management (Harbaugh et al., 2018)
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From page 90... ...
While discussed individually, in practice these categories are not mutually exclusive, and CPGs may be based on whatever single attribute or combination of attributes that is most clinically relevant. However, creating more granular CPGs for specific surgeries based on procedural nuances may be an opportunity in the future as the knowledge gaps regarding tissue injury, acute pain, and opioid requirements close with future research.
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From page 91... ...
. Timing of Procedure Surgical procedures may also be classified by the timing of intervention, such as elective, urgent, or emergency surgical procedures.
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From page 92... ...
. Given these nuances in care, the timing and acuity of surgical conditions will inform CPGs for acute pain following surgery.
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From page 93... ...
(2018) developed consensus recommendations for opioid prescribing after 20 common surgical procedures; stakeholders in this consensus process included surgeons, pain specialists, outpatient nurses, pharmacists, and patients.
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From page 94... ...
of all 17.2 and 136% MMEs for sacral Clinical Practice Guidelines for million ambulatory neuromodulation, mid-urethral Enhanced Recovery After Colon and or inpatient surgeries sling, and prolapse repair, Rectal Surgery from the American were vulvar, and respectively; there was a Society of Colon and Rectal female pelvic significant reduction (p<0.001) in Surgeons and Society of American procedures, for a MMEs prescribed after educational Gastrointestinal and Endoscopic rate of 59.2/100,000 intervention (Moskowitz et al., Surgeons -- "A multimodal, opioid people (Steiner et 2019)
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From page 95... ...
. Bree Collaborative Dental Guideline 68% of all opioids on Prescribing Opioids for Acute Pain prescribed were Prior to implementing an opioid Management -- Prescribe nonopioids as during surgical prescribing protocol for third first-line therapy (Bree Collaborative, dental visits (Gupta molar extractions, the mean 2017)
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From page 96... ...
. Michigan Acute Care Opioid Treatment and Prescribing Recommendations: Dental -- "For breakthrough or severe pain, short-acting opioids (e.g., hydrocodone, oxycodone)
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From page 97... ...
. inpatient surgeries received the least MMEs compared were for treatment with other fracture locations in Orthopaedic Trauma Association of fractures or opioid-naïve patients (Bhashyam Clinical Practice Guidelines for Pain dislocation of radius, et al., 2019)
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From page 98... ...
. 64.1% of 66 patients undergoing TKA stopped taking opioids within 6 weeks of surgery and had a mean equivalent of 18 oxycodone 5 mg pills remaining (Premkumar et al., 2019)
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From page 99... ...
. see also Open abdominal In 2014, out Among 2,392 patients undergoing Clinical Practice Guidelines for procedures of 17.2 million laparoscopic cholecystectomy, Enhanced Recovery After Colon and ambulatory or appendectomy, or hysterectomy, Rectal Surgery from the American inpatient surgeries, the median discharge prescription Society of Colon and Rectal 950,100 (5.5%)
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From page 100... ...
. Among 205 patients undergoing radical prostatectomy, a median of 225 mg OMEs were prescribed and 22.5 mg used, overall 77% of postdischarge opioid medication was unused, with 84% of patients requiring ≤112.5 mg OMEs (Patel et al., 2019)
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From page 101... ...
. Hill Guideline for Discharge Opioid Prescriptions After Inpatient General In pediatric patients, postoperative Surgical Procedures -- Postdischarge opioid prescriptions were opioid use is best predicted by usage significantly reduced for hernia the day before discharge from inpatient repair following an educational laparoscopic or open ventral hernia intervention: 4.2±2.9 versus repair (Hill et al., 2018a)
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From page 102... ...
. laceration; 2.6 of discharge; 8.5% of women million vaginal filled ≥1 opioid prescriptions 6 Mills Draft Opioid-Prescribing deliveries annually weeks after delivery (Prabhu et al., Guidelines for Uncomplicated (ACOG, 2018a; 2018)
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From page 103... ...
. million discharges associated with open Among patients undergoing Hill Guideline for Discharge Opioid abdominal surgery open nephrectomy or radical Prescriptions After Inpatient General (Carney et al., prostatectomy, the median OME Surgical Procedures -- Postdischarge 2017)
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From page 104... ...
. John Hopkins Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus -- Developed ranges for outpatient opioid prescribing at the time of discharge for partial or total thyroidectomy or for cochlear implant (Overton et al., 2018)
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From page 105... ...
"The maximum daily million ambulatory Of 16,647 TRICARE patients oral dose recommended for opioid or inpatient undergoing discectomy, 30.1% naïve, acute pain patients based on risk surgeries, 500,900 required ≥1 opioid refills (Scully of overdose/death is 50-mg MED." (2.9%) were spinal et al., 2018)
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From page 106... ...
. Among 70 patients who Orthopaedic Trauma Association underwent a preoperative opioid Clinical Practice Guidelines for Pain education intervention, there Management in Acute Musculoskeletal was a statistically significant Injury -- Prescribe the lowest effective decrease in opioid consumption immediate release opioid dose for the at 2 weeks (average 19%, p=0.1)
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From page 107... ...
NOTE: ACL=anterior cruciate ligament; CI=confidence interval; CPG=clinical practice guideline; IQR=interquartile range; MME=morphine milligram equivalent; NSAID=nonsteroidal anti-inflammatory drug; OME=oral morphine equivalent; THA=total hip arthroplasty; TKA=total knee arthroplasty.
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From page 108... ...
Opioid prescribing for acute pain for medical conditions may occur in primary care clinics, emergency departments (EDs) , inpatient hospital settings, and specialty practices such as pain clinics and practices devoted to rheumatology, urology and nephrology, neurology, or orthopedics.
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From page 109... ...
The committee then reviewed the literature to identify data on opioid prescribing in the primary care setting. Although there were numerous studies that looked at opioid prescribing for individual medical indications, the committee found two published studies that examined the prevalence of medical conditions and associated opioid prescriptions for acute pain and thus were useful in prioritizing medical indications for the purposes of the committee.
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From page 110... ...
Thus, as with surgical procedures, the committee did not identify any CPGs that contain specific recommendations for prescribing opioids to treat acute pain for the specific priority medical indications identified by the committee, although several of them do provide guidances on opioid therapy in the ED or inpatient settings (e.g., NHBLI, 2014)
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From page 111... ...
31% of all per 1,000 dental patients opioids prescribed increased from 130.58 in American Academy of Pediatric Dentistry for dental 2010 to 147.44 in 2015; Policy on Acute Pediatric Dental Pain patients were for those aged 11–18 Management -- Nonopioid analgesics as for nonsurgical years opioid prescriptions first-line agents for pain management; dental visits, increased from 99.71 in 2010 combining opioid analgesics with NSAIDs mostly restorative to 165.94 in 2015; median or acetaminophen for moderate/severe pain procedures; opioid day supply was 3 days with may decrease overall opioid consumption prescription rate a median daily dose of 33.33 (AAPD, 2018)
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From page 112... ...
ED visits for low Pain: A Systematic Review for an American opioids were back pain and at 968,000 College of Physicians Clinical Practice prescribed between (33.5%) ED visits for other Guideline -- No evidence to support the use 2006–2015, 6.9% conditions of the spine and of opioids for acute low back pain (Chou et were prescribed for back (Schappert and Rui, al., 2017)
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From page 113... ...
of back pain, there was a 6-fold tried and unsuccessful, the first opioid patients received variation in the adjusted, prescription for acute pain should be the a diagnosis of risk-standardized prescribing lowest possible effective strength of a short unspecified low rates that ranged from 12.0% acting opioid, not to exceed 100 MMEs back pain and to 78.2% (mean 50.4% total. Patients should be instructed that 3 about 2% received [standard deviation +/–16.4]
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From page 114... ...
. Institute of Health Economics, Alberta, Canada, Primary Care Management of Headache in Adults: Clinical Practice Guideline -- "Opioid analgesics (e.g., codeine, tramadol)
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From page 115... ...
. New England Pediatric Sickle Cell Consortium Management of Acute Pain in Pediatric Patients with Sickle Cell Disease (Vaso-Occlusive Episodes)
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From page 116... ...
. 2002–2006, there were an estimated 3.1 million ankle sprains occurred among an at-risk population of 1.5 billion person years for an incidence rate of 2.15/1,000 person years (Waterman et al., 2010)
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From page 117... ...
. NOTE: CI=confidence interval; CPG=clinical practice guideline; ED=emergency department; MME=morphine milligram equivalent; NHANES=National Health and Nutrition Examination Survey; OME=oral morphine equivalent; SCD=sickle cell disease.
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From page 118... ...
As in any clinical setting, the goals of managing patients with acute pain who are being discharged from the ED are to alleviate pain, restore function, and reduce the potential for adverse effects of medication. A common tenet in ED opioid prescribing guidelines is that given the known harms of opioid analgesia, ED clinicians should take every opportunity to use nonopioid and nonpharmacologic options to treat acute pain, especially on discharge, and to use opioid analgesics only when the benefits outweigh the risks (Strayer et al., 2017)
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From page 119... ...
Furthermore, as shown in Tables 5-2 and 5-3, the committee finds that there is evidence that excessive opioids are prescribed for acute pain associated with both surgical procedures and some medical conditions. Consequently, the committee also finds that some opioid-naïve patients who receive opioids for acute postoperative pain and acute pain episode from medical conditions may develop new chronic opioid use.
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From page 120... ...
2017. Dental guideline on prescribing opioids for acute pain management.
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From page 121... ...
2012. Resolution of acute pain following discharge from the emergency department: The acute pain trajectory.
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From page 122... ...
2018. Quantity of opioids consumed following an emergency department visit for acute pain: A Canadian prospective cohort study.
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From page 123... ...
2019. Clinical practice guidelines for pain management in acute musculoskeletal injury.
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From page 124... ...
1995. Setting priorities for clinical practice guidelines.
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From page 125... ...
2019. Clinical practice guideline: Tonsillectomy in children (update)
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2017. AAEM white paper on acute pain management in the emergency department.
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From page 127... ...
2017. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians.
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From page 128... ...
2017. Preemptive analgesia for postoperative hysterectomy pain control: Systematic review and clinical practice guidelines.
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From page 129... ...
2019. Statewide implementation of postoperative opioid prescribing guidelines.
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