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Guidelines: Inpatient Opioid Use to be Limited to Severe Pain

April 20, 2018

New recommendations from a Society of Hospital Medicine working group advise hospital-based clinicians to limit opioid prescribing as much as possible by restricting opioids to patients with severe pain or to patients with moderate pain who cannot take, or who do not respond to, nonopioid medications like ibuprofen and acetaminophen.

“The risk-to-benefit ratio of opioid and nonopioid therapy should be considered for all patients in determining the best initial management strategy,” said lead author Shoshana J. Herzig, MD, MPH, of Beth Israel Deaconess Medical Center and Harvard Medical School in a press release. “Clinicians tend to underestimate the benefit of non-opioid analgesics and overestimate the risks, while for opioids they overestimate the benefits and underestimate the risks. For most painful conditions, acetaminophen and nonsteroidal anti-inflammatory drugs have been shown to be equally or more effective with less risk of harm than opioids.”

The consensus statement, which applies to inpatients with acute, noncancer pain, appears in the April issue of the Journal of Hospital Medicine (doi: 10.12788/jhm.2980).

In patients who do warrant opioid treatment, the consensus statement recommends prescribing the lowest effective dose for the shortest duration possible, using immediate-release formulations, and giving the drugs orally whenever feasible to avoid overdose.

The recommendations also advise the importance of education. Patients, families, and caregivers should understand nonopioid pain management is available and may control pain as well as opioid medication. Education should also cover potential risks and side effects of opioid therapy, the patient’s expected course of recovery, and that the aim of opioid therapy is not only decreased pain but also increased function.

The consensus statement’s 16 recommendations stem from a systematic review of opioid-prescribing guidelines. Out of nearly 1000 guidelines, only 4 guidelines met selection criteria (a publish date of 2010 or later and addressing acute, noncancer pain management in the hospital setting). Among the 4 guidelines used to formulate the consensus statement, the working group pointed out an overall lack of guidance addressing inpatient, noncancer pain and a shortage of recommendations based on evidence from randomized controlled trials.

“Although most recommendations are based exclusively on expert opinion, our systematic review nonetheless represents the best guidance currently available,” said Dr Herzig. “Additional research will be necessary to understand the risk factors in hospitalized medical patients and to inform evidence-based, safe prescribing recommendations in this setting.”

Jolynn Tumolo

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