Key Hospitalist Clinical Practice Guidelines in 2017

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

January 16, 2018

In This Article

Opioid Administration

Veterans Affairs and Department of Defense

Recommend against initiation of long-term opioid therapy for chronic pain.

Recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments.

When pharmacologic therapies are used, non-opioids are recommended over opioids.

If prescribing opioid therapy for patients with chronic pain, a short duration is recommended. Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits.

For patients currently on long-term opioid therapy, ongoing risk-mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits are recommended.

Recommend against long-term opioid therapy for pain inpatients with untreated substance use disorder.

For patients currently on long-term opioid therapy with evidence of untreated substance use disorder, close monitoring is recommended, including engagement in substance use disorder treatment, as well as discontinuation of opioid therapy for pain with appropriate tapering.

Recommend against the concurrent use of benzodiazepines and opioids. Note: For patients currently on long-term opioid therapy and benzodiazepines, consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate.

Recommend against long-term opioid therapy for patients younger than 30 yr secondary to higher risk of opioid use disorder and overdose.

For patients younger than 30 yr currently on long-term opioid therapy, close monitoring and consideration for tapering when risks exceed benefits are recommended.

Implement risk-mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include ongoing, random urine drug testing (including appropriate confirmatory testing); checking state prescription drug-monitoring programs; monitoring for overdose potential and suicidality; providing overdose education; and prescribing of naloxone rescue and accompanying education.

Assess suicide risk when considering initiating or continuing long-term opioid therapy, and intervene when necessary.

Evaluate benefits of continued opioid therapy and risk for opioid-related adverse events at least every 3 mo.

If prescribing opioids, prescribe the lowest dose of opioids as indicated by patient-specific risks and benefits. Note: There is no absolutely safe dose of opioids.

As opioid dosage and risk increase, provide more frequent monitoring for adverse events, including opioid use disorder and overdose. Note: Risks for opioid use disorder start at any dose and increase in a dose-dependent manner. Risks for overdose and death significantly increase at a range of 20-50 mg morphine equivalent daily dose.

Recommend against opioid doses over 90 mg morphine equivalent daily dose for treating chronic pain. Note: For patients who are currently prescribed doses over 90 mg morphine equivalent daily dose, evaluate for tapering to reduced dose or to discontinuation.

Recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of long-term opioid therapy.

Taper to reduced dose or to discontinuation of long-term opioid therapy when risks of long-term opioid therapy outweigh benefits. Note: Abrupt discontinuation should be avoided unless required for immediate safety concerns.

Individualize opioid tapering based on risk assessment and patient needs and characteristics. Note: There is insufficient evidence to recommend for or against specific tapering strategies and schedules.

Provide interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high-risk and/or aberrant behavior.

Offer medication-assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder.

Alternatives to opioids for mild-to-moderate acute pain are recommended.

Use multimodal pain care, including non-opioid medications as indicated when opioids are used for acute pain.

If take-home opioids are prescribed, use immediate-release opioids at the lowest effective dose, with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated. Note: Patient education about opioid risks and alternatives to opioid therapy should be offered.

References

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