What are the latest guidelines for opiate (opioid) refills in the emergency room for pain management?

Latest Guidelines for Opioid Refills in the Emergency Room

Emergency departments should not routinely provide opioid refills, as opioid prescribing should be reserved only for patients with severe pain for whom alternative therapies are ineffective or contraindicated, and then only at the lowest effective dose for the shortest possible duration (typically 3 days or less). 1

Current Recommendations for Emergency Department Opioid Prescribing

Primary Principles

• Nonopioid analgesic therapies (both pharmacologic and nonpharmacologic) should be used preferentially over opioids 1
• For acute painful conditions requiring opioids, prescribe the lowest effective dose of short-acting opioids for the shortest feasible time 1
• Avoid prescribing opioids for acute exacerbations of chronic noncancer pain in the ED 1
• No automatic refills should be provided - each request should trigger a patient review 1

Specific Prescribing Guidelines

1. Duration of therapy:

   • Three days or less is typically sufficient for most acute pain conditions 1
   • More than seven days will rarely be needed 1
   • Each additional week of opioid use increases misuse risk by 20% 1

2. Dosing considerations:

   • Use immediate-release formulations only 1
   • Avoid long-acting opioids 1
   • Avoid doses greater than 90-200 mg morphine equivalents per day 1

3. Patient selection:

   • Reserve opioids for patients for whom alternative treatments:
     • Have not been tolerated or are not expected to be tolerated
     • Have not provided adequate analgesia or are not expected to provide adequate analgesia 2, 3

Risk Mitigation Strategies

When Opioids Must Be Prescribed

• Provide clear patient education about:
  • Safe storage of medications 1
  • Proper disposal of unused medication 1
  • Risks of sedation and respiratory depression 1
  • Avoidance of alcohol and sedatives while taking opioids 1
  • Risks of driving while taking opioids 1

Monitoring and Follow-up

• Inform primary care providers that requests for additional opioids should trigger a patient review rather than automatic refills 1
• If a patient is still requiring opioids beyond the normal healing period, they should be referred to pain specialists 1
• Patients taking opioids 90 days after surgery should be referred to pain specialists 1

Special Considerations

Chronic Pain Patients

• ED visits for chronic pain refills may indicate inadequate pain management or potential opioid misuse
• The ED is not the appropriate setting for managing chronic pain with opioids 1
• Patients with chronic pain requiring opioids should be referred to primary care or pain management specialists

Acute Pain in Surgical Patients

• Multimodal analgesia should be employed:
  • Regular paracetamol (acetaminophen) and/or NSAIDs if not contraindicated 1
  • Limited duration of immediate-release opioids only if necessary 1
  • Avoid compound analgesics as they hinder deprescribing 1

Common Pitfalls to Avoid

1. Automatic refills: Each additional refill increases the risk of opioid misuse by 40% 1

2. Prescribing opioids "just in case" pain continues longer than expected: This practice should be avoided 1

3. Prescribing long-acting opioids for acute pain: Only immediate-release formulations should be used for acute pain 1

4. Concurrent prescribing of opioids and benzodiazepines: This combination significantly increases overdose risk 1

5. Inadequate patient education: Patients must understand proper use, storage, and disposal of opioids 1

By adhering to these guidelines, emergency physicians can provide appropriate pain management while minimizing risks associated with opioid prescribing, including opioid use disorder, overdose, and death.