Opioid Stewardship Study Notes

Opioid Stewardship

Overview of Opioid Overdose Deaths (1999-2017)

  • Figure 1: Three Waves of the Rise in Opioid Overdose Deaths

    • Time frame: 1999-2017

    • Metric: Deaths per 100,000 population

    • Wave 1: Rise in Prescription Opioid Overdose Deaths by 2010.

    • Wave 2: Rise in Heroin Overdose Deaths.

    • Wave 3: Rise in Synthetic Opioid Overdose Deaths.

    • Other Synthetic Opioids: Include Tramadol and Fentanyl, both prescribed or illicitly manufactured.

    • Commonly Prescribed Opioids: Include natural & semi-synthetic opioids and Methadone.

    • Heroin: Another contributing factor to the series of overdose deaths.

    • Source: CDC MMWR.

Pain Management Strategies

Nonopioid Therapies for Pain Management

  • All patients should receive treatment for pain that:

    • Provides the greatest benefits relative to risks.

    • Maximizes the use of nonpharmacologic and nonopioid pharmacologic therapies due to their lower associated risks compared to opioids.

  • Recommendation: Maximize the use of non-pharmacologic and nonopioid therapies.

Specific Conditions for Non-opioid Management

  • Conditions suitable for non-opioid treatments include:

    • Low back or neck pain.

    • Dental pain.

    • Kidney stone pain.

    • Pain related to musculoskeletal injuries.

    • Minor surgery, e.g., tooth extraction.

    • Headaches, including migraines.

Non-opioid Treatments

  • Non-Pharmacologic Treatments:

    • Ice/Heat Application

    • Elevation

    • Rest

    • Immobilization

    • Exercise

    • Massage

    • Acupuncture

  • Non-opioid Medications:

    • Topical or oral NSAIDs.

    • Topical medications +/- menthol.

    • Acetaminophen.

    • Triptans and antiemetics.

    • Lidocaine injections or blocks.

    • Skeletal muscle relaxants.

Key Points and Recommendations

  • Collaboration with Mental and Behavioral Health: Integration is important for comprehensive care.

  • Consideration of Alternatives to Opioids: Explore nonopioid interventions as first-line therapies.

  • Partnership with Patients: Develop a treatment plan that includes:

    • Functional goals.

    • An exit strategy from opioid therapy if necessary.

  • Patient Education: Essential to inform about:

    • Risks and benefits of opioid therapy.

    • Importance of this information prior to initiating therapy, before increasing dosage, and upon reaching safe prescribing thresholds.

  • Treatment Duration Recommendations:

    • Acute pain: 3-7 days for non-traumatic or non-surgical pain.

    • Sub-acute pain: 30-day supply.

    • Chronic pain (non-cancer): 90-day supply.

  • Assessment of Patient Functionality: Conduct assessments early and repeatedly to gauge functionality.

  • Rebalancing Risks vs. Benefits: Regularly evaluate the necessity of continued opioid therapy vs. associated risks.

  • Re-evaluation of Opioid Treatment: Prescriber responsibilities include:

    • Re-assessing the effectiveness of the opioid treatment.

    • Implementing risk mitigation strategies, such as prescribing Naloxone if continuing opioid treatment is deemed necessary.

    • Recommended Dosage:

    • 50 morphine milliequivalents (mme) per day maximum.

    • Use of long-acting or extended-release formulations where applicable.