Initiation of Opioid Therapy for Acute Pain

Professional Standards Regarding Initiation of Opioid Therapy for Acute Pain

Preamble

This standard sets out the requirements for physicians when prescribing opioids for the management of acute pain in the out-patient setting. It does not apply for in-patient settings.

This standard aligns with the Framework for FMRAC’s Members on a Regulatory Approach to Physicians who Prescribe Opioids. As well, this standard builds upon the Canadian Guidelines for Chronic Non-Cancer Pain in 2017, previously endorsed by the College to improve opioid prescribing.

Professional Standards

When opioids are considered for acute pain management, they must be prescribed only when necessary, in the lowest effective dose, and for the shortest duration required. Three days will often be sufficient; more than seven days will rarely be needed. (CDC Guidelines for Prescribing Opioids for Chronic Pain).

Physicians must:

perform and document a relevant and appropriate clinical assessment;
assess the patient’s level of pain and consider multimodal treatment measures for pain control including non-narcotic analgesics, adjunctive medications, and non-pharmacology therapies;
screen for risk factors for opioid misuse and use caution when prescribing opioids for these patients;
check the Nova Scotia Prescription Monitoring Program (NSPMP) for the medication profile of patients before prescribing opioids;
explain treatment goals, duration of therapy, side effects, risks, benefits, and harms of opioids and document informed consent;
initiate opioid treatment for acute pain with immediate release opioids and avoid use of long acting or extended release formulations;
not exceed a seven-day supply of opioid medications unless extenuating circumstances are clearly documented in the medical record or the patient has been reassessed;
collaborate and communicate with the patient’s health care team;
avoid prescribing opioids and benzodiazepines concurrently whenever possible – document your reasons for concurrent prescribing of these medications as concurrent prescribing is generally contraindicated;
use caution in prescribing sedative hypnotics, carisoprodol, and tramadol concurrently with opioids; and
inform patients how to safely and securely store opioids and dispose of any unused supply.

Risks of opioid misuse are greater with:

personal history of substance use disorder involving any substance, including alcohol;
family history of substance use problems or addiction;
concomitant psychiatric problems or diagnosis;
concomitant use of other psychiatric medications, benzodiazepines, other prescription opioids;
exposure to physical, sexual, or emotional abuse or trauma especially at young age;
duration of days of the initial opioid prescription (greater number of days associated with continuation of opioid therapy); and
higher morphine milligram equivalents per day (use lower doses if prescribed).

Definitions

Acute Pain
The normal, predicted physiological response to a noxious chemical, thermal or mechanical stimulus and is associated with invasive procedures, trauma, and disease. Generally acute pain is self-limited lasting usually no more than three months in duration.

Opioid-Naive Patient
Opioid-naive patients are those who have not received opioids in the 30 days prior to the acute event or surgery.