(0–7 Days Following Trauma or Surgery)

In most cases, acute pain can be treated effectively with non-opioid or non- pharmacological options (e.g., elevation, ice) With more severe acute injury (e.g., significant trauma, fracture, crush injury, postoperative pain, extensive burns), short-term use of opioids may be appropriate Initial opioid prescriptions should not exceed seven days for most situations, and two to three days of opioid medication will often suffice. If an individual needs medication beyond three days (or beyond the average expected time for initial healing) a reevaluation of the patient should be performed prior to further opioid prescribing Physical dependence on opioids can occur within only a few weeks of continuous use, so great caution needs to be exercised during this critical recovery period.

Assessment

  • Review medical history, including records from previous providers, when available.
  • Administer a physical exam to determine diagnosis and appropriate care. Document baseline function and baseline pain.
  • Determine whether the injury can be treated without opioids or if the severity of the injury justifies the risks of opioid therapy.

Non-Opioid Treatment

  • Help patients set reasonable expectations concerning recovery from the injury. Educate them about the healing process and the benefits of appropriate activity.
  • Reassure the patient that some pain is to be expected and that it will subside in time. Over-the-counter (OTC) medications will provide significant relief from pain in many situations and can be relied upon for ongoing pain relief a after the acute period is over.
  • Patients should improve in function and pain and resume their normal activities in a matter of days to weeks, depending upon the diagnosis. Reevaluate those who do not follow the normal course of recovery.

Opioid Treatment

  • If the severity of the injury indicates that limited opioid treatment is appropriate, before prescribing, you:
    • Should perform a simple screen for substance abuse (e.g., ORT). Individuals in active recovery are at high risk of being “triggered” by even small amounts of opioids, and you can inadvertently put them in harm’s way with your prescription. Those with a history of attempted suicide or overtaking opioids should be prescribed the least amount of medication necessary.
    • Should identify other prescribed medications or conditions that would preclude co-prescribing opioids. Benzodiazepines have a synergistic effect with opioids.12
    • Must inform the patient about the risks and side effects of opioids. Many young people who became dependent on opioids say they never were informed of its risks.
    • May want to have the patient sign a treatment agreement if the patient returns requesting a re ll of opioids. A urine drug screen and PDMP query should be performed prior to writing the second prescription. Continued prescribing might indicate the need for the patient to sign a treatment agreement.
  • Opioid prescriptions should be for the shortest appropriate period of time, usually two to three days of treatment post injury or surgery, followed by over-the-counter treatments if further medications are indicated.
  • Opioid overprescribing puts your patients at risk. Four out of five recent heroin initiates (79.5 percent) previously used prescription pain killers.13
  • Some major surgeries, injuries, and certain disease states may require longer periods of opioid treatment. Justification for prescribing outside the guidelines should be documented in the patient record.
  • If pain continues, a reevaluation is usually indicated because:
    • Pain beyond the expected timeframe may indicate a complication (e.g., infection, re-injury, displacement, dehiscence).
    • Complaint of ongoing pain may indicate an unrecognized substance-use disorder, which may require greater scrutiny and an alternative treatment modality.
  • At each follow-up visit, assess and document pain and function, educate the patient on the importance of self-management and appropriate activity.

Patient Instructions

  • Dosage instructions need to clear. PRN prescribing should be only as liberal as necessary, as it can lead to inadvertent large doses (e.g., hydrocodone/acetaminophen 5/325 one to two every three to six hours can be as much as 50 mg MED a day—a lot of medication for an opioid-naïve individual).
  • The number of pills you prescribe sets up “dosing expectations” for the patient. Prescribing #40 pills for a time-limited painful experience may send an inadvertent message to the patient, giving permission for the casual use of opioids.

Tools

  • Screening tools for substance abuse: ORT (Appendix A), and SOAPP-R (Appendix B)
  • Screening tools for function: Oswestry Disability Index (ODI) (Appendix M) and PEG-3 (Krebs et al 2009) (Appendix N)
  • Screening tools for co-occurring mental health conditions: PHQ-4, GAD-7
  • Prescription Drug Monitoring Program (PDMP) (See http://www.orpdmp.com/PDMP_2015v02262015.pdf, page 15)
Acute Pain