Risk Management Strategies and Considerations for Opioid Prescribing

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. The majority of overdose deaths involve opioids, and the amount of opioids prescribed per person is still around three times higher than it was in 1999. Additionally, the COVID-19 pandemic coincided with an increase in overdose-related 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 have sought to provide strategies and recommendations to assist practitioners treating patients who have 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 Pain

• Talk to patients about realistic expectations for pain management, and provide education about opioid benefits, risks (common and serious), and alternatives. Involve patients’ families and caregivers (as permitted) in informed consent and patient education discussions.
• Avoid prescribing extended-release and long-acting (ER/LA) opioids for acute pain (e.g., postoperative pain or trauma-related pain). Instead, prescribe the lowest effective dose of immediate-release opioids.
• Check state prescription drug monitoring databases for prescription opioids and other controlled substances patients have received from other prescribers, 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.⁴
• When prescribing immediate-release opioids, order a limited quantity that will suffice until the provider can reassess the patient at a follow-up visit. The Centers for Disease Control and Prevention (CDC) recommends that clinicians evaluate patients to assess the benefits and risks for opioids at least every 2 weeks.⁵
• 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 immediate-release opioids are tapered.⁶

Pain Management Strategies for Subacute and Chronic Pain

• Do not consider opioids as first-line or routine therapy for subacute or chronic pain. 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, determine whether nonopioid medications might be effective.
• When considering opioids for subacute or 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).
• Consider requesting toxicology screening to assess for prescribed and nonprescribed medications and controlled substances that increase the risk of overdose when combined with opioids.
• Assess patients’ suicide risk when considering initiating or continuing ER/LA opioid therapy, and develop a plan for intervention when necessary.
• When initiating opioid treatment for a patient who has subacute or chronic pain, establish treatment goals with the patient, including realistic goals for pain and function as well as 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.
• Prescribe the lowest effective dose of immediate-release opioids. ER/LA opioids should be prescribed only for severe, continuous pain and only for patients who have received certain dosages of immediate-release opioids for at least 1 week.
• Specify a short treatment duration when prescribing opioids for subacute or chronic pain management. Assess the patient within 1 to 4 weeks of the initial prescription or dose escalation. After initial assessment, 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 who are prescribed opioids, particularly if they are at increased risk of opioid overdose.
  • Providing comprehensive patient education that takes into account patient preferences and values.
• 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.
• Use caution when prescribing concurrent opioid medications and other central nervous system depressants, and consider whether the benefits outweigh the risks.
• 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, discuss the approach with the patient and 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. Include patients in decisions about how quickly tapering will occur and when pauses in tapering might be warranted. Frequently follow up (at least monthly) with patients who are tapering their opioids.⁷

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 CDC's Opioid Overdose website.

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¹ Centers for Disease Control and Prevention. (2018, December 19). Understanding drug overdoses and deaths. 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 [last reviewed]). Prescribing practices: Changes in opioid prescribing practices. Retrieved from www.cdc.gov/drugoverdose/deaths/prescription/practices.html; Centers for Disease Control and Prevention, Understanding drug overdoses and deaths; Centers for Disease Control and Prevention. (2022, June 2 [last reviewed]). Drug overdose deaths: Death rate maps & graphs. Retrieved from www.cdc.gov/drugoverdose/deaths/index.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 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 Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recommendations and Reports, 71(3), 1–95. doi: http://dx.doi.org/10.15585/mmwr.rr7103a1

⁶ Dowell, et al. CDC clinical practice guideline for prescribing opioids for pain — United States, 2022; 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, et al., Prescription of opioids for acute pain in opioid naïve patients.

⁷ Dowell, et al., CDC clinical practice guideline for prescribing opioids for pain — United States, 2022; 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/; Pino, et al., Prescription of opioids for acute pain in opioid naïve patients.

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