Do chronic pain medications cover pain from acute procedures?

From the Guidelines

Chronic pain medications are generally not sufficient to cover pain from acute procedures. According to the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1, opioids might not be more effective than nonopioid therapies for some acute pain conditions, and their use might negatively affect recovery and function.

Key Considerations

• Patients on chronic pain medications like opioids should continue their regular regimen but typically need additional acute pain management due to tolerance and potential opioid-induced hyperalgesia.
• Supplemental short-acting analgesics should be provided based on the procedure's severity, including options like additional short-acting opioids, local anesthetics, NSAIDs, or acetaminophen.
• A multimodal approach combining different medication classes often works best, and patients with chronic pain may require consultation with pain specialists to develop appropriate acute pain management plans.

Acute Pain Management Options

• Nonopioid medications, such as NSAIDs (e.g., ketorolac or ibuprofen) or acetaminophen, are recommended as first-line therapy for acute pain management by guidelines like the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) 1.
• Local anesthetics can be effective for procedural pain, and their use may reduce the need for systemic analgesics.
• Short-acting opioids may be necessary for severe acute pain, but their use should be carefully monitored due to the risk of adverse events and long-term opioid use.

Important Evidence

• A systematic review found that opioids were probably less effective than NSAIDs for surgical dental pain and kidney stone pain, and similarly effective as NSAIDs for low back pain 1.
• The evidence review also found that opioids were associated with increased risk for short-term adverse events, including nausea, dizziness, and somnolence, compared to NSAIDs or acetaminophen 1.

From the FDA Drug Label

Morphine sulfate tablets are indicated for the management of acute and chronic pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.

• Chronic pain medications like morphine can be used for acute pain from procedures, as they are indicated for the management of both acute and chronic pain.
• The drug label explicitly states that morphine sulfate tablets are for use in patients with severe enough pain to require an opioid analgesic, regardless of whether the pain is acute or chronic 2.

From the Research

Chronic Pain Medications and Acute Procedures

• Chronic pain medications may not be sufficient to cover pain from acute procedures, as they are often designed to manage ongoing pain rather than sudden, severe pain 3, 4.
• Acute pain management strategies often involve a multimodal approach, using a combination of medications such as acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids to target different pain pathways 4, 5.
• The choice of analgesic for acute pain in the emergency department lacks a clear evidence base, but studies suggest that a combination of ibuprofen and acetaminophen may be a viable nonopioid alternative to opioids 6.

Acute Pain Management

• Effective acute pain control is mandatory after injury, and a thoughtful approach includes managing patient expectations and ensuring interventions affect the domain of pain that is uncontrolled 4.
• A responsible acute pain management approach includes knowing the relative strengths of prescribed opioids and using a standardized approach to opioid prescribing at discharge to minimize diversion 4.
• Continuing medication for opioid use disorder, such as methadone or buprenorphine, may be beneficial for patients experiencing acute pain, as it can reduce the need for additional opioids and improve pain management 7.

Multimodal Analgesia

• A multimodal approach to analgesia, using a combination of medications with differing mechanisms of action, can provide additive and/or synergistic effects and reduce side effects 5.
• Agents used in multimodal analgesia include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine, which can be used to target different pain pathways 5.