Opioid Prescribing: Navigating Through a Crisis

Marcy A. Metzgar and Laura M. Cascella, MA, CPHRM

Opioid addiction is arguably one of the most significant public health crises in the United States over the past few decades. Increases in opioid prescribing and consumption in the late 1990s and first decade of the 2000s fueled an epidemic of overdoses, a national heroin crisis, and a rise in deaths from synthetic opioids.¹

Opioid prescribing has been declining since 2012; yet, these powerful analgesics still present serious concerns. Estimates suggest that more than 130 people die every day from opioid-related drug overdoses, and the amount of opioids prescribed per person is still around three times higher than it was in 1999. Additionally, opioids contribute to more than two-thirds of all drug overdose deaths.²

Although the solution to the opioid crisis might seem straightforward — i.e., significantly reducing or stopping prescribing — the reality is far more complex. Despite significant risks, opioids can be an effective treatment option for some of the millions of Americans who suffer from pain. Further, many patients have come to rely on these medications. Abrupt tapering or discontinuation can threaten patient health and safety.³ Unfortunately, this leaves healthcare providers in the unenviable position of undertaking the risky and often confounding task of determining when opioid prescribing is appropriate.

Various resources and guidelines about opioid prescribing and pain management have sought to provide strategies and recommendations to assist practitioners treating patients who have acute or chronic pain, as detailed below. Clinicians who prescribe opioids should consider these recommendations as part of a pain management approach that includes assessing patients’ individual circumstances and the potential risks and benefits of opioid therapy.

Pain Management Strategies for Acute Pain⁴

• Talk to patients about realistic expectations for pain management, and provide education about opioid risks. Involve patients’ families and caregivers (as permitted) in informed consent and patient education discussions.
• Avoid prescribing long-acting opioids for acute pain (e.g., postoperative or trauma-related pain). Instead, prescribe the lowest effective dose of short-acting opioids.
• Check state prescription drug monitoring databases and screen patients for risk factors associated with opioid misuse.
• Only prescribe the quantity of opioids necessary for acute pain that is severe enough to require opioid treatment. Research shows that opioids are overprescribed for surgical procedures and emergency department visits for painful conditions.⁵
• When prescribing short-acting opioids, order a limited quantity that will suffice until the patient is reassessed at a follow-up visit.
• Ask patients who have acute pain to follow up if their pain is not resolving as expected. Establish expectations for follow-up with primary care providers, surgeons, and other providers as appropriate.
• Consider patient-specific factors that might affect duration and doses related to opioid treatment (e.g., older age, comorbidities, other medications, etc.)
• Use treatment approaches that combine modalities and emphasize nonpharmacological interventions and nonopioid analgesics, particularly as short-acting opioids are tapered.

Pain Management Strategies for Chronic Pain⁶

• Consider recommending self-management strategies and other nonpharmacological therapies as first-line treatment options for patients who have chronic pain.
• If pharmacological therapy is necessary to manage a patient’s chronic pain, consider whether nonopioid medications might be effective.
• When considering opioids for chronic pain treatment, evaluate patients for risks related to misuse or harm (e.g., a history of substance abuse, mental health conditions, sleep-disordered breathing, pregnancy, or renal or hepatic deficiency).
• Assess patients’ suicide risk when considering initiating or continuing long-term opioid therapy, and develop a plan for intervention when necessary.
• When initiating opioid treatment for a patient who has chronic pain, establish treatment goals with the patient, including realistic goals for pain and function and criteria for stopping or continuing opioids.
• Prior to prescribing opioids, assess the patient’s baseline pain and function (e.g., using the PEG scale), conduct an informed consent conversation with the patient, and review the risks and benefits of opioid therapy as well as alternative therapies.
• Specify a short treatment duration when prescribing opioids for chronic pain management. Reassess the patient within 1–4 weeks of the initial prescription. After initial reassessment, continue to reevaluate the patient and review the benefits and potential risks of opioid treatment at least every 3 months.
• Use ongoing risk mitigation strategies for patients who require long-term opioid therapy. Strategies include:
  • Reassessing pain and function and comparing results with baseline measurements
  • Testing for illicit drugs
  • Consulting state prescription drug monitoring programs
  • Monitoring for overdose potential
  • Assessing for opioid use disorder
  • Offering naloxone to patients at increased risk of opioid overdose
  • Providing relevant patient education
• Avoid prescribing benzodiazepines with opioids whenever possible. For patients who are taking both medications, consider tapering the dose of one or both if the risks outweigh the benefits. Additionally, seeking specialty consultation is advisable.
• During patient reevaluations, determine whether to continue, adjust, taper, or stop opioids based on benefits and risks. When deciding to taper or discontinue opioid therapy, create a patient-specific plan that considers factors such as type of opioid, dosage, treatment duration, and the patient’s physical and mental health.
• Take a gradual approach to tapering or discontinuing opioids and monitor the patient for serious withdrawal symptoms, worsening pain, and/or psychological distress.

More Information

For more information and resources related to opioid prescribing and overdose prevention, see MedPro’s Risk Resources: Opioid Prescribing & Pain Management. For complete guidelines and free online training modules, visit the Centers for Disease Control and Prevention’s Opioid Overdose website.

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¹ Centers for Disease Control and Prevention. (2018, December 19). Opioid basics: Understanding the epidemic. Retrieved from www.cdc.gov/drugoverdose/epidemic/index.html; Kolondy, A., Courtwright, D. T., Hwang, C. S., Kriener, P., Eadie, J. L., Clark, T.W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36 (1), 559-574. doi: 10.1146/annurev-publhealth-031914-122957

² Centers for Disease Control and Prevention. (2019, August 13). Prescribing practices: Changes in opioid prescribing practices. Retrieved from www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html; U.S. Department of Health and Human Services. (2019, September 4). What is the U.S. opioid epidemic? Retrieved from www.hhs.gov/opioids/about-the-epidemic/index.html; Kolondy, et al. The prescription opioid and heroin crisis; Centers for Disease Control and Prevention. (2019, June 27). Drug overdose deaths. Retrieved from www.cdc.gov/drugoverdose/data/statedeaths.html

³ Centers for Disease Control and Prevention. (2019, April 24). CDC advises against misapplication of the guideline for prescribing opioids for chronic pain [Press release]. Retrieved from www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

⁴ Department of Veterans Affairs, & Department of Defense. (2017, February). VA/DoD clinical practice guideline for opioid therapy for chronic pain. Retrieved from www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf; Pino, C. A., & Covington, M. (2019, May 14). Prescription of opioids for acute pain in opioid naïve patients. UpToDate. Retrieved from www.uptodate.com/contents/prescription-of-opioids-for-acute-pain-in-opioid-naive-patients#H1623647593

⁵ Pino, et al. Prescription of opioids for acute pain in opioid naïve patients.

⁶ Department of Veterans Affairs, & Department of Defense, VA/DoD clinical practice guideline for opioid therapy for chronic pain; Strong, C. (Ed.). (2017, February 23). Opioids for chronic pain: A new clinical guideline from the VA and Department of Defense. Clinical Advisor. Retrieved from www.clinicaladvisor.com/pain-management-information-center/clinical-guideline-for-opioids-and-chronic-pain/article/639780/; Dowell, D., Haegerich, T.M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain — United States, 2016. Morbidity and Mortality Weekly Report, Recommendations and Reports, 65(1). DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1; Pino, et al., Prescription of opioids for acute pain in opioid naïve patients.

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