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Opioid Prescribing [Adult]

Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department (June 2012)

 Complete Clinical Policy on Opioid Prescribing (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based EDs.

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with acute
noncancer pain or an acute exacerbation of chronic noncancer pain.

Exclusion Criteria. This guideline is not intended to address the long-term care of patients with cancer or
chronic noncancer pain.

Critical Questions

1. In the adult ED patient with noncancer pain for whom opioid prescriptions are considered, what is the utility of state prescription drug monitoring programs in identifying patients who are at high risk for opioid abuse?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. The use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shopping.

2. In the adult ED patient with acute low back pain, are prescriptions for opioids more effective during the acute phase than other medications?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.
(1) For the patient being discharged from the ED with acute low back pain, the emergency physician should ascertain whether nonopioid analgesics and nonpharmacologic therapies will be adequate for initial pain management.

(2) Given a lack of demonstrated evidence of superior efficacy of either opioid or nonopioid analgesics and the individual and community risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics rather than routinely prescribed.

(3) If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (eg, <1 week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion.

3. In the adult ED patient for whom opioid prescription is considered appropriate for treatment of new-onset acute pain, are short-acting schedule II opioids more effective than short-acting schedule III opioids?

Level A recommendations. None specified.

Level B recommendations. For the short-term relief of acute musculoskeletal pain, emergency physicians may prescribe short-acting opioids such as oxycodone or hydrocodone products while considering the benefits and risks for the individual patient.

Level C recommendations. Research evidence to support superior pain relief for short-acting schedule II over schedule III opioids is inadequate.

4. In the adult ED patient with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing opioids on discharge from the ED outweigh the potential harms?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

(1) Physicians should avoid the routine prescribing of outpatient opioids for a patient with an acute exacerbation of chronic noncancer pain seen in the ED.
(2) If opioids are prescribed on discharge, the prescription should be for the lowest practical dose for a limited duration (eg, <1 week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion.
(3) The clinician should, if practicable, honor existing patient-physician pain contracts/treatment agreements and consider past prescription patterns from information sources such as prescription drug monitoring programs.

Purpose of ACEP’s Clinical Policies

Clinical Findings and Strength of Recommendations