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Opioid Prescription in Acute Pain

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1. Randomised controlled trial: Non-opioid analgesia is as effective as opioid management in acute pain and supports a change in prescribing practice to help address the ‘opioid epidemic’

in other patient groups is required. Context Opioid analgesics are the first-line treatment for moderate to severe pain in the emergency department (ED) despite concerns about the ‘opioid epidemic’. The opioid epidemic refers to a rapid increase in the use of opioids in the USA and Canada that began in the 1990s, recently reframed as a public health emergency. Long-term opioids use often begins with a prescription for an acute pain problem, and is associated with an increased risk of dependence (...) , Iyengar R , Bothra A , et al . A Tool to Assess Risk of De Novo Opioid Abuse or Dependence . 4. Chang AK , Bijur PE , Esses D , et al . Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity Pain in the emergency department: a randomized controlled clinical trial . 5. Oxford Pain Group . Oxford league table of analgesics in acute pain . 2007 6. Moore RA , Wiffen PJ , Derry S , et al . Non-prescription (OTC) oral analgesics for acute pain - an overview of Cochrane reviews

2018 Evidence-Based Nursing

2. Recent advances in acute pain management: understanding the mechanisms of acute pain, the prescription of opioids, and the role of multimodal pain therapy (PubMed)

Recent advances in acute pain management: understanding the mechanisms of acute pain, the prescription of opioids, and the role of multimodal pain therapy In this review, we discuss advances in acute pain management, including the recent report of the joint American Pain Society and American Academy of Pain Medicine task force on the classification of acute pain, the role of psychosocial factors, multimodal pain management, new non-opioid therapy, and the effect of the "opioid epidemic (...) ". In this regard, we propose that a fundamental principle in acute pain management is identifying patients who are most at risk and providing an "opioid free anesthesia and postoperative analgesia". This can be achieved by using a multimodal approach that includes regional anesthesia and minimizing the dose and the duration of opioid prescription. This allows prescribing medications that work through different mechanisms. We shall also look at the recent pharmacologic and treatment advances made in acute pain

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2017 F1000Research

3. Adverse outcomes associated with opioid prescription for acute low back pain: a systematic review protocol. (PubMed)

Adverse outcomes associated with opioid prescription for acute low back pain: a systematic review protocol. Acute low back pain (ALBP) is the top cause of global disability, demonstrating a significant impact on individuals and society and demanding the need for appropriate management. There is a trend towards an increasing number of opioid prescriptions for ALBP despite the lack of investigation for its various short- and long-term outcomes. The objective of this review is to examine adverse (...) guidelines published to alert clinicians in prescribing opioids for ALBP due to its likelihood of misuse, yet there is little change in prescribing patterns. To date, there is an absence of systematic information about the outcomes of prescription opioid in patients with ALBP. We will address this gap by providing evidence that will be useful for clinical practice.PROSPERO CRD42016033090.

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2017 Systematic reviews

4. The content validation of the self-reported misuse, abuse and diversion (SR-MAD) of prescription opioids instrument for use in patients with acute or chronic pain. (PubMed)

The content validation of the self-reported misuse, abuse and diversion (SR-MAD) of prescription opioids instrument for use in patients with acute or chronic pain. Establishing content validity is an essential component of instrument development.To assess the content validity and patient interpretation of the Self-Reported Misuse, Abuse and Diversion of Prescription Opioids (SR-MAD) instrument.A cross-sectional, qualitative study was conducted in patients with chronic or acute pain. Patients (...) with pain. The most common chronic pain conditions were back pain (68%), neck pain (32%), and osteoarthritis (25%). Overall, most patients understood the meaning of each question and were able to describe each item using their own words. Many patients reported that some questions were not applicable to them but understood the meaning of the questions as well as the need to ask questions about misuse, abuse, and diversion of opioid medications. Minor revisions to the SR-MAD wording, response options

2017 Current medical research and opinion

5. Practice Advisory: FDA Boxed Warning on Immediate-Release Opioid Medications and All Prescription Opioids

22nd, 2016, the U. S. Food and Drug Administration (FDA) for immediate-release opioid pain medications. As part of these changes, the FDA is now requiring a new boxed warning (“black box” warning) about the serious risks of misuse, abuse, addiction, overdose, and death on all prescription opioids. The boxed warning will also include a precaution that chronic maternal opioid use during pregnancy can result in neonatal abstinence syndrome (NAS, referred to in the FDA warning as “neonatal opioid (...) is the interpretation of the warning and potential impact on care of the pregnant woman. Health care providers and patients who may not be fully aware of these nuances surrounding opioid prescribing for pregnant women may assign an inordinate amount of attention to the boxed warning. As a result, patients may be denied access to medically indicated opioid prescriptions (either for pain management or opioid-assisted therapy), potentially resulting in an abrupt discontinuation of opioids. Evidence clearly shows

2016 American College of Obstetricians and Gynecologists

6. Opioid Prescription in Acute Pain

Opioid Prescription in Acute Pain Opioid Prescription in Acute Pain Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Opioid (...) Prescription in Acute Pain Opioid Prescription in Acute Pain Aka: Opioid Prescription in Acute Pain , Opioid Informed Consent , Narcotic Prescription for Acute Pain Precautions , Acute Opiate Patient Education From Related Chapters II. Precautions Ask patients if there are prescriptions they should not take or do not want to take before prescribing Some patients, sober from as history, may decline s to prevent relapse Orman and Starr in Herbert (2018) EM:Rap 18(2):15 III. Management: Patient Education s

2018 FP Notebook

7. Are opioids effective in the treatment of chronic low back pain?

, they should use the lowest possible doses with frequent reassessment of the risks and benefits of treatment for their patients. Yet, in stark contrast to these recommendations, an analysis of data from the Medical Expenditure Panel Survey estimates that 12.6% of patients with back pain not caused by an acute injury received opioid prescriptions, and that rate was significantly higher (26.2%) in patients with a positive PHQ-2 screen for depression at the time of prescription. 4 Further support (...) , Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med . 2017;166(7):514-530. Smith JA, Fuino RL, Pesis-Katz I, et al. Differences in opioid prescribing in low back pain patients with and without depression: a cross-sectional study of a national sample from the United States. Pain Rep . 2017;2(4):e606. Shmagel A, Ngo L

2019 Clinical Correlations

8. Evaluation of the Impact of an Online Opioid Education Program for Acute Pain Management. (PubMed)

for analysis.Clinicians (N = 167) reported improvement in knowledge and perceived competence. Controlling for other aspects of knowledge evaluated, learning to construct a safe opioid taper plan for acute pain, distinguishing between short- and long-acting opioids, and safely initiating opioids for acute pain were significantly associated with increased self-reported likelihood of incorporating the Washington state Prescription Monitoring Program (P = 0.003), using multimodal analgesia (P = 0.022), and reducing (...) Evaluation of the Impact of an Online Opioid Education Program for Acute Pain Management. The University of Washington instituted a policy requiring all credentialed clinicians who prescribe opioids to complete a one-time education activity about safe and responsible opioid prescribing. A scenario-based, interactive online learning module was developed for opioid management of acute pain in hospitalized adults. This study examined the impact of the education module on learners' knowledge

2019 Pain Medicine

9. Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations

= prescription drug monitoring program; UDM = urine drug monitoring. Figure 2 Consensus recommendations. PDMP = prescription drug monitoring program; UDM = urine drug monitoring. Discussion and Recommendations Question 1: Which UDM Test(s) Should Be Used and in Which Patients Prescribed Opioids for Chronic Pain Should the Tests Be Used According to a Medical Literature Review, Clinical Experience, Clinical Chemistry of Drug Testing, and Practical Considerations? Expert Panel Recommendations Use definitive (...) current drug use, and drug use detected by oral fluid testing or self-report: 100%, 92.9%, and 84.7%, respectively; specificity for these measures: 73.5%, 94.1%, and 96.2%, respectively [ ] – Relevant Literature Several tools for predicting and determining current risk of aberrant medication-taking behaviors (e.g., lost prescription, request for early refill), opioid misuse, and opioid use disorder are reported in the literature [ ]. In a pain clinic–based study, a semistructured clinical interview

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2018 Publication 4890876

10. Opioid use after laparoscopic hysterectomy: prescriptions, patient use, and a predictive calculator. (PubMed)

surveyed about their pain and pain medication use.Ninety-eight percent of patients were prescribed an opioid for acute postoperative pain. The median opioid prescription was for 150 morphine milligram equivalents, equivalent to 20 tablets of oxycodone 5 mg, while median patient postoperative use was 37.5 morphine milligram equivalents, equivalent to 5 tablets of oxycodone 5 mg. Ninety percent of patients had leftover opioids at 2 weeks after surgery, and most leftover opioids were stored in an unsecure (...) morphine milligram equivalents) or a low opioid user (defined as taking 37.5 morphine milligram equivalents or less).On average, surgeons prescribed 4 times the amount of opioids than was needed for patients undergoing laparoscopic hysterectomy for acute postoperative pain control. Individualizing patients' opioid prescriptions based on preoperative risk factors could help reduce excess prescription opioids.Copyright © 2018 Elsevier Inc. All rights reserved.

2019 American Journal of Obstetrics and Gynecology

11. Raising Awareness to Prevent Prescription Opioid Overdoses

by doctors to treat moderate to severe pain, but have serious risks and side effects. Anyone who takes prescription opioids can become addicted to them. Families across the county are dealing with the health, emotional, and economic effects of the opioid epidemic. The opioid overdose epidemic is a public health emergency and Americans of all races and ages are being killed by opioid overdoses. Rx Awareness campaign tackles prescription opioids is CDC’s latest effort in the fight against the opioid (...) community. if you are prescribed opioids for pain and work with your doctor to ensure you are getting the safest, most effective pain management possible. find the right care and treatment. Anyone who takes prescription opioids can become addicted and help is available if you or someone you know is battling opioid use disorder. and increase awareness in your community about the risk and dangers of prescription opioids. By sharing campaign materials you can broaden the reach of the message

2018 CDC Public Health Matters

12. Chronic Opioid Therapy for Chronic Non-Cancer Pain

prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than that needed for the expected duration of pain severe enough to require opioids. (CDC 2016) For acute, subacute, and perioperative prescribing, general principles from the AMDG guideline are listed here. Refer to the full AMDG guideline for more detailed recommendations. Acute phase (0–6 weeks post episode of pain or surgery) • Check the state’s Prescription Monitoring Program (PMP) before (...) Chronic Opioid Therapy for Chronic Non-Cancer Pain ? 2010 Kaiser Foundation Health Plan of Washington. All rights reserved. 1 Patients on Chronic Opioid Therapy for Chronic Non-Cancer Pain Safety Guideline Major Changes as of September 2016 2 Guideline Scope 2 Preventing Conversion from Acute to Chronic Opioid Therapy 3 Washington State Law 4 Expectations for Kaiser Foundation Health Plan of Washington Providers 4 Managing Chronic Opioid Therapy (COT) 5 Contraindications to opioid therapy 5

2016 Kaiser Permanente Clinical Guidelines

13. Management of Opioid Therapy (OT) for Chronic Pain

ui d el i n e f o r O p ioid T h e r a p y for Ch r on ic Pa in February 2017 Page 4 of 198 B. Risk Mitigation 46 51 70 71 75 75 75 80 81 81 88 99 100 105 105 110 116 116 120 122 C. Type, Dose, Duration, Follow-up, and Taper of Opioids D. Opioid Therapy for Acute Pain Appendix A: VA Signature Informed Consent Appendix B: Urine Drug Testing A. Benefits of Urine Drug Testing B. Types of Urine Drug Testing Appendix C: Diagnostic and Statistical Manual of Mental Disorders for Opioid Use Disorders (...) Recommendations 14 and 15). Strong against Reviewed, New- replaced 13. We recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of long-term opioid therapy. Strong against Reviewed, New- replaced 14. We recommend tapering 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. Strong

2017 VA/DoD Clinical Practice Guidelines

14. Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. (PubMed)

Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. The United States is in the midst of an opioid epidemic, and opioid use disorder often begins with a prescription for acute pain. The perioperative period represents an important opportunity to prevent chronic opioid use, and recently there has been a paradigm shift toward implementation of enhanced recovery after surgery (ERAS) protocols (...) to the pre-period rate (P = .399). Subgroup analysis showed that in patients with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge, the rate of discharge opioid prescription was 72% (95% CI, 61%-83%).This study is the first to report discharge opioid prescribing practices in an ERAS setting. Although an ERAS intervention for colorectal surgery led to an increase in opioid-free anesthesia and multimodal analgesia

2017 Anesthesia and Analgesia

15. Deaths from Opioid Overdosing: Implications of Coroners’ Inquest Reports 2008–2012 and Annual Rise in Opioid Prescription Rates: A Population-Based Cohort Study (PubMed)

Deaths from Opioid Overdosing: Implications of Coroners’ Inquest Reports 2008–2012 and Annual Rise in Opioid Prescription Rates: A Population-Based Cohort Study In the late 1990s multiple physicians and advocacy organizations promoted increased use of opioids for the treatment of acute, chronic and cancer pain. There has been an exponential growth in opioid prescribing in the last 20 years in the United States of America, in Australia, and in other developed Western countries (...) was associated with the increases in the numbers of opioid prescriptions.A multifaceted national public health approach is needed to bring together the various stakeholders involved with pain management, opioid dependence, opioid availability and opioid diversion. There needs to be a targeted approach to educate current and future medical practitioners regarding the appropriate use of opioid prescriptions for the management of pain, as well as a strengthening of primary, secondary and tertiary resources

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2017 Pain and therapy

16. Acute Pain Is Associated With Chronic Opioid Use After Total Knee Arthroplasty. (PubMed)

, discharge prescriptions, and changes in postoperative versus preoperative dose categories. Sensitivity analysis examined associations with dose escalation.Rates of chronic significant opioid use (21% overall) differed in patients with lower versus higher acute pain (36% vs 64% of the overall cohort). After propensity matching (total n = 20,926 patients) and adjusting for all significant factors, lower acute pain was associated with less chronic significant opioid use (rates 12% vs 16%), smaller (...) discharge prescriptions (ie, supply <30 days and daily oral morphine equivalent <30 mg/d), and more reduction in dose, all P < 0.001. In sensitivity analysis, dose escalation was 15% less likely with lower acute pain (odds ratio, 0.85; 95% confidence interval, 0.80-0.91).Acute pain predicts chronic opioid use. Prospective studies of efforts to reduce acute pain, in terms of long-term effects, are needed.

2018 Regional Anesthesia and Pain Medicine

17. Opioid prescribing and risk mitigation implementation in the management of acute pain: Results from The National Dental Practice-Based Research Network. (PubMed)

Opioid prescribing and risk mitigation implementation in the management of acute pain: Results from The National Dental Practice-Based Research Network. Minimal information exists regarding the consistency and correlates of dentists' implementation of risk mitigation strategies when prescribing opioids, including risk screening, prescription drug monitoring program (PDMP) use, and patient education.The authors conducted a Web-based, cross-sectional survey among practicing dentist members (...) or acetaminophen (18%) to one-half or more of their patients needing management of acute pain. Higher levels of opioid prescribing were associated significantly with less consistent implementation of PDMP use (r = -0.20) and patient education (r = -0.11).Most dentists reported infrequent PDMP use and counseling patients regarding risks, storage, and disposal of opioids. Higher frequency of opioid prescribing was associated with less consistent risk mitigation implementation.When opioid prescribing is indicated

2018 Journal of the American Dental Association

18. Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines. (PubMed)

Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines. Pain is common among hospitalized patients. Inpatient prescribing of opioids is not without risk. Acute pain management guidelines could inform safe prescribing of opioids in the hospital and limit associated unintended consequences.To evaluate the quality and content of existing guidelines for acute, noncancer pain management.The National Guideline Clearinghouse, MEDLINE via (...) . Most recommendations were based on expert consensus. The guidelines recommended restricting opioids to severe pain or pain that has not responded to nonopioid therapy, using the lowest effective dose of short-acting opioids for the shortest duration possible, and co-prescribing opioids with nonopioid analgesics. The guidelines generally recommended checking the prescription drug monitoring program when prescribing opioids, developing goals for patient recovery, and educating patients regarding

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2018 Journal of Hospital Medicine

19. Provider-Targeted Behavioral Interventions to Prevent Unsafe Opioid Prescribing for Acute Pain in Primary Care

care for patients with acute non-cancer pain. Aim 1) Among opioid naïve primary care patients with acute non-cancer pain, compare the effect of the provider-targeted behavioral interventions (opioid justification and provider comparison), individually and in combination, on initial opioid prescription, initial use of non-opioid management, and patient-reported pain and function. Aim 2) Compare the effect of the 2 provider-targeted behavioral interventions, individually and in combination, on unsafe (...) opioid prescribing and transition to chronic opioid therapy. Aim 3) Assess provider satisfaction and experience with the provider-targeted behavioral interventions. Hypotheses: Aim 1, H1a: Compared with the guideline (usual care) alone, the addition of the opioid justification and provider comparison behavioral interventions will be associated with a decreased proportion of opioid prescription and increased proportion of non-opioid management at the initial outpatient visit for acute non-cancer pain

2018 Clinical Trials

20. Opioid Prescribing for Acute Postoperative Pain After Cutaneous Surgery. (PubMed)

Opioid Prescribing for Acute Postoperative Pain After Cutaneous Surgery. Little information is available to predict which patients require opioid analgesia following cutaneous surgery. When opioids are indicated, information regarding the optimal opioid agent selection and dosage is lacking.To make recommendations for opioid prescription after cutaneous surgery.A PubMed literature search was conducted to review the available literature. Recommendations are presented on the basis of available (...) evidence and the opinion of the authors.Most patients undergoing cutaneous surgery do not require opioid analgesia. For those who do, the duration of pain warranting opioid analgesia is generally less than 36 hours. Opioid refill requests warrant a follow-up visit to ascertain the cause of ongoing pain after excisional procedures.The recommendations are not based on prospective randomized trials.The presented recommendations for opioid prescription practice are derived from available evidence

2018 Journal of American Academy of Dermatology

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