Opioid-related ADE prevention practices:
- Total daily opioid dose is calculated using a conversion calculator, verified by pharmacy and discussed with the physician as needed.
- Total daily dose does not exceed 90 MME/day; exception per hospital policy (cancer patients, etc.) utilized.
- Patients with continuous opioid infusions (patient-controlled analgesia and regular infusions) have continuous monitoring of respiratory status using capnography or pulse oximetry.
- Criteria and directions for the use of naloxone as a rescue agent are contained in the order set if an opioid is prescribed.
- Co-prescribing of two or more opioids is monitored by pharmacy with interventions as needed.
- Co-prescribing of benzodiazapines with opioids is monitored by pharmacy with interventions as needed.
- Buprenorphine, methadone and naltrexone are initiated for patients during inpatient stay as appropriate.
Assessment and monitoring best practices:
- Measure and document patient weights in metric units only. Do not rely on a patient’s stated weight, a healthcare provider’s estimated weight or a documented weight from a previous encounter.
- Verify and document a patient’s opioid status (naïve versus tolerant) and type of pain (acute versus chronic) before prescribing and dispensing extended-release and long-acting opioids.
- In the nursing assessment, include:
- vital signs (blood pressure, temperature, pulse, respiratory rate);
- pain level;
- respiratory effort/quality;
- sedation level; and
- risk factors including age, sleep apnea, obesity, snoring and concomitant use of sedating medications.
- Monitor opioid-related side effects such as nausea, vomiting, constipation, central nervous system side effects, allergic reactions, pruritus or other opioid-related adverse effects.
- All appropriate antidotes, reversal agents and rescue agents are readily available. Have standardized protocols and/or coupled order sets in place that permit the emergency administration of all appropriate antidotes, reversal agents and rescue agents used in the facility. Have directions for use/administration readily available in all clinical areas where the antidotes, reversal agents and rescue agents are used.
- Order sets are standardized to the use of one or two drugs with a single concentration for PCA use.
- Orders for basal dosing during PCA use is restricted to opioid tolerant patients.
- A single standardized order set is used for PCA management.
- Computerized provider order entry and pharmacy information systems alert providers to serious drug interactions/contraindications.
- Opioid infusions are prepared/provided by the pharmacy.
- Alert practitioners when extended-release and long-acting opioid dose adjustments are required due to age, renal or liver impairment or when patients are prescribed other sedating medications.
- Hospital has an automatic stop on patients being discharged on opioids with a pharmacy review and interventions if needed.
- Hospital has guidelines for how much opioid-based medicines (dose, number of pills and refills) can be prescribed :
- from ED; and
- at discharge.
- Monitoring is required for any patient receiving methadone and buprenorphine. Gradual reduction is recommended for transitioning patients to and from the hospital who have been taking these agents.
- Patient is given a naloxone prescription upon discharge.
- Patient has a plan of care for opioid management after discharge.
Patient and family engagement:
- Patients who are identified to have opioid use disorder are offered a referral to a medication-assisted treatment center, behavioral health or other addictionologist, as needed.
- Patient and family members are given education and counselling on opioid risk and safety.
CDC guidelines for prescribing opioids for chronic pain
- Opioids are not first-line therapy. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.
- Establish goals for pain and function. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
- Discuss risks and benefits. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
- Use immediate-release opioids when starting. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
- Use the lowest effective dose. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥ 50 morphine milligram equivalents per day and should avoid increasing dosage to ≥ 90 MME per day or carefully justify a decision to titrate dosage to ≥ 90 MME per day.
- Prescribe short durations for acute pain. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
- Evaluate benefits and harms frequently. Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
- Use strategies to mitigate risk. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥ 50 MME per day) or concurrent benzodiazepine use are present.
- Review prescription drug monitoring program data. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months.
- Use urine drug testing. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
- Avoid concurrent opioid and benzodiazepine prescribing. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
- Offer treatment for opioid use disorder. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.