What is the recommended approach for prescribing opioids for short-term acute pain management in an outpatient clinic, particularly for patients who are opioid-naive or have a history of substance abuse?

Prescribing Opioids for Short-Term Acute Pain in Outpatient Settings

Reserve opioids only for patients with acute pain when nonopioid therapies are expected to be ineffective or contraindicated, and when prescribed, use the lowest dose of immediate-release formulations for ≤3 days in most cases, rarely exceeding 7 days. 1

Initial Assessment and Risk Stratification

Before considering opioids, conduct a focused assessment that includes:

• Pain severity and expected duration - Document the specific acute pain condition and anticipated pain trajectory 1
• Prior opioid exposure - Check if the patient is opioid-naïve or has previous opioid use, as even 5 days of opioid therapy increases risk of long-term use 1
• Substance use history - Screen for current or past alcohol use disorder, drug use disorders, or mental health conditions, which increase risk of opioid use disorder (OUD) 1
• Concurrent medications - Identify use of benzodiazepines, muscle relaxants, or other CNS depressants, which substantially increase overdose risk 1, 2
• Check prescription drug monitoring program (PDMP) - Review to identify existing opioid prescriptions or patterns suggesting misuse 1

First-Line Treatment: Nonopioid Approaches

Maximize nonopioid therapies before considering opioids, as evidence shows opioids provide no clinically significant advantage over nonopioid alternatives for acute pain. 1

Pharmacologic Options

• NSAIDs and acetaminophen - Use as first-line for most acute pain conditions 3
• Topical NSAIDs - Recommended for non-low back musculoskeletal injuries 3
• Adjunctive medications - Consider muscle relaxants for acute low back pain if first-line agents inadequate 3

Nonpharmacologic Options

• Ice, heat, elevation, rest, immobilization, or exercise as appropriate for the specific condition 1

When Opioids Are Deemed Necessary

Medication Selection

Prescribe only immediate-release, short-acting opioid formulations - never extended-release/long-acting (ER/LA) opioids for acute pain. 1

• Avoid methadone and transdermal fentanyl - These have unpredictable pharmacokinetics and should only be prescribed by clinicians with specific training 1
• Never prescribe codeine or tramadol for patients <12 years, adolescents with obesity/sleep apnea/lung disease, post-tonsillectomy patients <18 years, or breastfeeding patients 4
• Equianalgesic dosing - Schedule II and III opioids have equivalent efficacy at equianalgesic doses; selection can be based on formulary and patient factors 1

Starting Dosage

For opioid-naïve patients, start with 5-15 mg oral morphine equivalents every 4-6 hours as needed (not scheduled). 1, 5

• The lowest starting dose is typically 20-30 morphine milligram equivalents (MME) per day 1
• Example: Oxycodone 5 mg/acetaminophen 325 mg, one tablet every 4-6 hours as needed 1, 5
• Prescribe "as needed" rather than scheduled dosing to prevent unnecessary opioid exposure 1

Duration of Therapy

Limit initial prescriptions to ≤3 days for most acute pain conditions, with a maximum of 7 days only when medically justified. 1, 6

• Data show that among patients receiving a 7-day supply, <25% require refills for most acute pain conditions 6
• Risk of long-term opioid use increases markedly after just 5 days of therapy 1
• Never prescribe more than a 7-day supply for initial acute pain treatment 1

Absolute Contraindications to Co-Prescribing

Do not prescribe opioids simultaneously with benzodiazepines or other sedative-hypnotics/muscle relaxants for acute pain. 1, 2

This combination:

• Substantially increases respiratory depression and overdose risk 1, 2
• Should be avoided entirely in patients with sleep apnea, respiratory disorders, elderly patients ≥65 years, or those with substance use history 2

Special Populations

Patients with Chronic Pain Experiencing Acute Exacerbation

Do not routinely prescribe opioids for acute exacerbations of chronic noncancer pain. 1

• Evidence shows opioids offer no clinically significant benefit over nonopioid alternatives for this population 1
• If opioids are already prescribed for chronic pain, coordinate with the existing prescriber rather than adding additional opioids 7

Patients with History of Substance Use Disorder

• Do not allow concerns about manipulation to prevent adequate pain treatment when objectively indicated 7
• Offer naloxone to all patients at risk for overdose 1
• Consider consultation with addiction medicine or pain specialist 7

Mandatory Patient Education and Documentation

Before prescribing, discuss with patients:

• Expected benefits are modest - Opioids provide statistically significant but clinically small improvement over placebo, with no advantage over nonopioid alternatives 1
• Immediate adverse effects - Nausea, vomiting, constipation, dizziness, drowsiness occur commonly 1
• Serious risks - OUD development, respiratory depression, overdose death can occur even with short-term use 1
• Plan for discontinuation - Emphasize opioids are temporary and include taper plan if used around-the-clock >few days 1
• Safe storage and disposal - Provide specific instructions and naloxone information 1, 4

Document in the medical record:

• Specific indication for opioid therapy 2
• Discussion of risks, benefits, and alternatives 1
• PDMP review findings 1, 2
• Plan for duration and reassessment 2

Critical Pitfalls to Avoid

• Never use opioids as monotherapy - Always combine with nonopioid analgesics and nonpharmacologic approaches 4, 3
• Never prescribe ER/LA formulations for acute pain - These are inappropriate for opioid-naïve patients with acute pain 1
• Never exceed 7 days for initial prescription - Longer duration dramatically increases risk of long-term use 1
• Never co-prescribe with benzodiazepines - This combination substantially increases mortality risk 1
• Never dismiss legitimate pain needs due to substance use history - Undertreating acute pain can worsen outcomes 7