For severe acute pain due to surgeries and medical conditions, there is a lack of guidance on the appropriate type, strength, and amount of opioid medication that clinicians should prescribe to patients, says a new report from the National Academies of Sciences, Engineering, and Medicine. A standardized process for developing clinical practice guidelines (CPGs) would provide trustworthy evidence-based criteria for prescribing opioids, help clinicians assess the risks and benefits of prescribing opioids, and identify areas where more evidence and research is needed, says Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. The report defined acute pain as sudden and lasting up to 90 days.
The report recommends two frameworks — an analytical framework and an evidence evaluation framework — that medical professional societies, health care organizations, and state, national, and local agencies could use to develop CPGs for prescribing opioids to manage acute pain.
Rigorous evidence and CPGs based on that evidence help clinicians make the best possible decisions about patient care. Despite widespread efforts over the last five years to reduce opioid prescribing, opioids are commonly overprescribed for acute pain. In addition, the amount of opioids prescribed for acute pain varies by provider, hospital, and geographical region.
Excessive opioid prescribing does not only place patients at risk for opioid addiction and overdose; leftover prescription opioids may also be misused by family members. After surgery, patients consume only half of the opioids prescribed, the report says. In addition, between 6 percent and 14 percent of opioid-naïve patients who receive opioid prescriptions after surgery or in the emergency department continue to use them six to 12 months later, increasing their risk of misuse.
“Clinicians who prescribe opioids have to balance two distinct goals: relieving a patient’s severe pain, while minimizing the potential public health harms of opioid misuse and the resulting emotional distress to families and communities,” said Bernard Lo, president of the Greenwall Foundation and chair of the committee that wrote the report. “We hope the frameworks we suggest in the report will lead to more evidence-based prescribing guidelines that can help clinicians provide high-quality care to patients experiencing acute pain.”
The report identifies priority surgical procedures and acute medical conditions for which evidence-based CPGs for opioid prescribing would be desirable. These procedures and conditions were selected based on their prevalence or frequency and evidence of inappropriate prescribing of opioids.
High-priority surgical procedures include cesarean (C-section) delivery, total knee replacement, and wisdom tooth removal; and acute medical conditions include low back pain, sickle cell disease, migraines, and kidney stones. For example, childbirth is the most common reason for hospital admission and C-section delivery is the most common surgical procedure in the United States, but there are no evidence-based guidelines for opioid prescribing after C-section or vaginal delivery. In other common conditions, like low back pain, there is a lack of evidence that opioids are more effective than alternatives such as over-the-counter medications or physical therapy. In these situations, a trustworthy CPG can help physicians relieve patients’ acute pain and prevent the risks of excessive prescribing of opioids, the report says.
The committee’s CPG development approach provides a stepped process, beginning with the analytical framework. The analytical framework depicts the evidence and potential data gaps that need to be assessed before making an opioid prescribing recommendation; the intermediate outcomes of different prescribing strategies (such as refill requests, unused pills, misuse, or diversion); and health outcomes (such as pain relief, improved quality of life, adverse effects, mortality, and morbidity).
Next, clinicians and developers of CPGs should use the evidence evaluation framework to grade the quality of existing evidence and the strength of recommendations they make. Sources of evidence may include randomized controlled trials, observational studies, and quality improvement initiatives.
The report also identifies important gaps in current CPGs for opioid prescribing in acute pain and recommend more research to address:
- How alternative interventions affect the need for opioids and the outcomes of prescribed opioids
- The outcomes of opioid prescribing strategies in different patient populations
- The impact of clinical setting on opioid prescribing strategies (for example, emergency departments, primary care clinics, or ambulatory surgical facilities)
- How the amount of opioids prescribed and left over affect health outcomes
The study — undertaken by the Committee on Evidence-Based Clinical Practice Guidelines for Prescribing Opioids for Acute Pain — was sponsored by the U.S. Food and Drug Administration. The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.
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