Guidance limited for treating acute pain
Prescribing a short-term opioid to patients who haven't recently or ever taken a controlled substance might boost their vulnerability to later addiction.
Amid the opioid crisis, doctors daily face patients in acute pain, whether it's a throbbing ankle sprain or the racking journey of a kidney stone. Compared with chronic pain, though, acute pain has fewer guidelines available, according to physicians and pain experts.
At the same time, physicians can't help but worry that prescribing a short-term opioid to someone who hasn't recently or ever taken a controlled substance might boost their vulnerability to later addiction, said Scott Weiner, MD, MPH, an emergency physician at Boston's Brigham and Women's Hospital, who also directs the opioid stewardship program there.
Dr. Weiner pointed to one study in Colorado, published in 2015 by the Annals of Emergency Medicine, which found that roughly half of 4,800 patients coming through an urban ED over five months were opioid-naïve, defined as not having filled an opioid prescription for at least a year prior to the visit. But among those 775 opioid-naïve patients who filled an opioid prescription, 17% became recurrent users, still taking an opioid a year or so later.
Perhaps in some of those cases, the patient might have suffered an injury that resulted in long-term pain, Dr. Weiner said. “But you have to wonder that maybe some of it was that we were prescribing [opioids], and we were the ones that got the patient hooked.”
Still, while the frequent perception is that emergency physicians prescribe the bulk of opioids, they are far outpaced by other specialties, particularly primary care doctors, Dr. Weiner said. He coauthored a recent analysis of opioid prescribing in Ohio from 2010 to 2014, which determined that family practice and internal medicine physicians together wrote 39% of the prescriptions for which a physician specialty was available. Orthopedic surgeons were responsible for 5.8%, and emergency physicians were responsible for 5%, according to the data, published in 2017 by Pain Medicine.
To guard against opening the door to chronic use, or later pill diversion by others, the onus is on the doctor to weigh the need for and ideal duration of an opioid, said Dr. Weiner and other pain specialists. Nonopioids can be tried first, as well as other nondrug strategies like heat or massage, depending on the pain symptoms. The experts also advise frankly talking to patients about their pain relief expectations.
Even so, doctors should guard against becoming totally “opioid phobic” amid public health and other pressures, including the proliferation of state prescribing laws, said Daniel Alford, MD, FACP, a professor of medicine at Boston University School of Medicine who also directs the Clinical Addiction Research and Education (CARE) Unit at Boston Medical Center.
“I think we shouldn't be fearful of prescribing a couple of days of opioids in people who have severe acute pain if that's going to help them get functional again,” Dr. Alford said, enough, for example, to enable the patient to fully engage in physical therapy. “But we should be very judicious in how much we give them based on how long we think they actually need it.”
Limited guidance
The CDC recently released guidelines on chronic pain but also noted that “long-term opioid use often begins with the treatment of acute pain.” To that end, the authors recommended that clinicians use the lowest effective dose of intermediate-release opioids. Three days or less is often sufficient, and “more than seven days will rarely be needed,” according to the guidelines, which were published in 2016 by Morbidity and Mortality Weekly Report.
In citing guidance from medical organizations on acute pain, the CDC guidelines noted only a few that were nondental, including one published in 2012 by the American College of Emergency Physicians (ACEP). That guideline, which covered acute noncancer pain and acute exacerbations of chronic pain, issued a Level B recommendation to prescribe short-acting opioids for acute musculoskeletal pain, “while considering the benefits and risks for the individual patient.”
In his work as a primary care physician, Dr. Alford said that he devotes more time to treating patients for chronic pain than acute. Acute pain in some ways seems “much easier and less problematic,” he said, in part because it's predictable, following in the wake of trauma or surgery, and most often will improve on its own. “That all being said,” he added, “there is a need to also focus on the cautious use of opioids in treating severe acute pain in addressing our opioid crisis.”
More guidelines are in the works. At its annual meeting in fall 2017, ACEP passed a resolution to promote the development of national guidelines regarding opioid prescribing for acute pain in the ED, according to a spokesman. ACP issued guidelines for acute and chronic back pain in 2017, which have been endorsed by the American Academy of Family Physicians (AAFP). ACP is also in the early stages of gathering evidence to develop joint guidance with AAFP for treating acute musculoskeletal pain.
In the meantime, state legislators continue to pass opioid prescribing laws, at least 23 by July 2017, according to the National Conference of State Legislatures (NCSL). Most limit first-time prescriptions to a certain number of days, usually seven, and set exceptions for chronic pain, according to a NCSL report from August 2017. But some of the limits for acute noncancer pain are shorter, no more than three days in Kentucky for an initial prescription, and five days in New Jersey and North Carolina.
Opioid alternatives
In their daily practice, primary care doctors might be called upon to treat all sorts of presentations of acute pain, whether it's a headache, back pain, a rotator cuff injury, an elbow sprain, or sudden knee discomfort, said Devan Kansagara, MD, FACP, associate professor of medicine at Oregon Health & Science University in Portland. Sometimes chronic back pain can flare into an acute form as well, said Dr. Kansagara, a member of the committee for ACP's back pain guidelines.
One challenge in easing acute back pain, defined as less than four weeks in duration, is that research on medication options is limited, Dr. Kansagara said. “It just hasn't been studied well,” he said.
Based on the data that are available, there's moderate-quality evidence that NSAIDs can result in a small improvement in pain intensity, according to the clinical guidelines, published April 4, 2017, in Annals of Internal Medicine. A similar level of evidence showed that skeletal muscle relaxants achieved short-term pain relief compared with a placebo over the course of a week, according to the guidelines.
Surprisingly, acetaminophen didn't seem to help, Dr. Kansagara said. Corticosteroids also didn't show any benefit.
Other nondrug options were explored. Moderate-quality evidence determined that applying a heat wrap moderately improved pain relief. Both acupuncture and massage provided a short-term reduction in pain, based on low-quality evidence.
But opioids were not included as a treatment option, in large part because of the risk-benefit tradeoff, Dr. Kansagara said. By and large, the patient should not run the risk of dependence if the vast majority of acute back pain recedes on its own, he said.
“I think the key message that we as clinicians need to give to our patients with acute low back pain is that most of you are going to get better with time,” Dr. Kansagara said. “In the meantime, as your body makes itself better, we don't want to harm you.”
One frequently cited back pain study, published in 2015 by JAMA, found that an NSAID might work just as well as an opioid or a muscle relaxant. The study, which tracked 323 patients seeking help at an ED after no longer than two weeks of back pain, looked at the effectiveness of naproxen versus two other drug options.
One group got placebo pills with 500-mg naproxen twice daily. The other two groups, along with the naproxen, took either cyclobenzaprine (5 mg) or oxycodone/acetaminophen (5 mg/325 mg). The patients who were prescribed drugs in addition to the naproxen didn't report any improvement in pain or physical function one week later, the researchers found.
One option for other acute pain scenarios is to prescribe combination therapy such as acetaminophen with an NSAID, Dr. Alford said. One Cochrane review, which looked at 39 prior reviews of over-the-counter medications in postoperative pain, found that ibuprofen and acetaminophen worked the best, with 70% of patients reporting adequate relief.
A stair-step approach
Doctors worried about the possibility of addiction should keep in mind that patients coping with acute pain usually don't experience the euphoric effects of an opioid, Dr. Alford said. Neither should a patient on medication-assisted treatment (MAT), such as buprenorphine or methadone, because those drugs block all but the analgesic properties of an opioid, he said.
For doctors worried about the addictive vulnerability of the patient in the office, there are screening tools, such as the Opioid Risk Tool (ORT) or the Screener and Opioid Assessment for Patients with Pain (SOAPP). But they're typically designed with the patient who has chronic pain in mind, Dr. Alford said.
A doctor can watch out for risk factors embedded in a patient's medical record, such as a personal or a family history of substance use, said Matthew Bair, MD, an ACP Member and an associate professor of medicine at Indiana University School of Medicine in Indianapolis. Patients with anxiety or depression also are considered more vulnerable to opioid-related problems, he said.
Other worrisome signs, such as attempts at early refills, might be more difficult to pick up unless the doctor has built an ongoing relationship, Dr. Bair said. “In an initial interview with acute pain, where it's the first time you are seeing the patient, I think that would be very difficult.” But primary care doctors have an inherent advantage, he said. “We know our patients, and we hopefully have some continuity where we can see whether there is a pattern or not.”
But what about a patient with a history of addiction, now in recovery and not on MAT, who needs acute relief? Those patients are frequently worried themselves about the potential for relapse if treated with an opioid analgesic, Dr. Alford said.
One approach that Dr. Alford has used is to prescribe acetaminophen in combination with an NSAID, but also to give the patient a prescription for a limited supply of opioid, such as oxycodone. He advises the patient to go ahead and take the opioid if the pain doesn't improve within a few hours.
As a precautionary step, Dr. Alford said, he might also prescribe a shorter duration of the opioid than is typically needed for that type of acute pain crisis. But he lets the patient know to call if he needs a bit more.
It's a fine line to walk, Dr. Alford said, as studies have shown that people with a history of opioid use disorder are more sensitive to pain. (It's not understood, he said, whether that heightened pain sensitivity is an inborn genetic vulnerability to developing an opioid use disorder, or whether the drug use over time has altered the individual's opioid receptors in some way.)
But holding back on that opioid and forcing patients to suffer with unrelieved acute pain can potentially set them up as well, Dr. Alford said. “The question is, what's more of a trigger to relapse, exposure to the opioid for a couple of days, or unrelieved terrible pain?”
As always in medicine, compassion is important, Dr. Weiner said. But, he added, “Any time we start an opioid, it shouldn't be a light decision. It takes an extra step of thought if this is the right medicine for the patient.”
Regardless of the medicine that's used, doctors should educate patients about reasonable expectations, Dr. Weiner said.
“We shouldn't expect that the pain level will get to zero,” he said. “If you have a fracture, it hurts. If you throw out your back, it hurts. The idea is that we make it so it's not to the point where it's completely impeding your function to do basic activities of daily living.”
