Goals
Opioids should be prescribed only when necessary, in the lowest effective dose, and for the shortest duration necessary. Prescribing more opioid than necessary can result in leftover pills, which are then available for diversion and inappropriate use. Opioid doses greater than 50 daily oral morphine equivalents or duration greater than 3 days are cited for increased risk for misuse, overdose, chronic use, and diversion.¹
Patient Centered Approach
Expectations for pain related to injury, a surgical procedure, or a medical condition, should be discussed with patients and their care providers. The goal is to find the lowest effective analgesic dose as well as the amount needed before re-evaluation is necessary.
Optimizing with adjuncts
Utilize multimodal pain control methods to maximize non-opioid analgesics. Prescribe opioids only when necessary, and only for duration of most intense pain that is likely to require opioids. Encourage patients to use acetaminophen and nonsteroidal anti-inflammatory drugs first, and to take opioids only when necessary.
Dose of opioids
The goal is to provide the lowest effective dose required to provide adequate pain relief. The dose of opioids consumed the 24 hours prior to discharge is a predictor of opioids that may be required after discharge. Determine the total daily amount of opioid the patient takes, convert this to oral morphine equivalents. The discharge opioid should be lower to avoid unintentional overdose caused by incomplete cross-tolerance and individual differences in opioid pharmacokinetics. Consider using this tool² to help calculate the oral morphine equivalents.
Duration of opioids
Opioids should be prescribed in no greater quantity than that required for the expected duration of pain severe enough to require opioids. Some institutions have surgery based reccomendation³, consider using these as a reference. For most acute painful conditions unrelated to major surgery or trauma, a three-day supply should suffice.
Prescribing Naloxone
For all patients who are prescribed opioids, providers should discuss the availability of naloxone and consider prescribing it especially to patients who are at increased risk of opioid overdose (eg: patients who are prescribed a daily dose of > 50 oral morphine equivalents and also using medications that depress the central nervous such as benzodiazepines).
Tapering Opioids
The decision to taper or discontinue opioids should be made collaboratively with each individual patient. Opioid tapering should proceed at a rate slow enough to minimize the likelihood that opioid withdrawal symptoms will occur, along with use of supportive measures that reduce risks and maximize chances of success. The CDC has a guide⁴ to tapering, and in general:
- A decrease of 10% per month
- Coordinate with a treatment expert
- Ensure patient has psychosocial support
- Reassess, adjust accordingly, and monitor
https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf
https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf