Pharmacists play a crucial role in combating the opioid epidemic as well as ensuring patients get adequate pain management treatment. It is imperative that pharmacists in any setting understand and apply evidence-based strategies when it comes to prescribing opioids and managing opioid therapy.
Related CE course for pharmacists: Pain Management: Evidence-Based Guidance for Prescribing Opioids
Appropriately determining when to start prescribing opioids
- Consider non-opioids (NSAID, acetaminophen) for common types of acute pain
- Opioids should be used as needed vs scheduled for acute pain
- Prescribe immediate-acting opioids over long-acting opioids for acute pain
- Consider discussing a discontinuation plan if opioids are ineffective
Non-opioid treatments are as effective as opioid medications for many acute pain conditions. Many patients with acute pain, such as back pain, sprains, strains, dental pain, etc., can be effectively treated using NSAIDs and acetaminophen. Evaluation of the patient is important to determine the underlying cause of pain.
When providers determine that opioid treatment is necessary for acute pain, immediate-release opioids at the lowest dose should be prescribed. Opioids for acute pain should be used on an as-needed basis versus a scheduled basis.
Pharmacists play a crucial role in educating patients on the potential side effects, risk of addiction, potential benefits, and alternative options of opioid medications. In addition to educating on opioid therapy, pharmacists can help patients determine how opioid therapy will be stopped.
Selecting opioids and determining dosages
- Evaluate individual benefits and risks if considering continued opioid use
- Continue with the lowest possible dose and limit dose increases
- Most patients do not experience additional benefit with >50 MME/day
Long-term use of opioid therapy comes with risks such as misuse, death, and overdose. Determination of long-term usage of opioids should be considered cautiously after discussing risks and benefits with the patient.
Data shows that daily doses of greater than 50 MME of opioids have minimal additional benefits of pain control compared to less than 50 MME of opioids. The risk of opioid misuse and overdose increases in those patients taking over 50 MME per day.
Tapering opioids
- If benefits do not outweigh risks of continued opioid therapy, develop a taper plan
- Opioid tapers are most successful when health care providers collaborate with the patient and other health care team members
- Slow tapers (<10% per month) lead to better-tolerated tapers
- The team approach (Physician, Pharmacist, Nurse, Care Manager, etc.) is beneficial and allows for close follow-up with the patient.
Patients who are more engaged and interested in tapering medications often have a more successful taper. Health care providers should collaborate with the patient as they develop a taper plan. Tapers may be more successful when the entire health care team is involved, as this often leads to closer follow-up with the patient.
Short-term and rapid tapers increase the risk of exacerbation of pain, withdrawal symptoms, suicidal ideation, or worsening anxiety. Every patient should receive education on withdrawal symptoms while tapering opioids.
Deciding duration of initial opioid prescription and conducting follow-up
- Prescriptions should be provided for the shortest duration needed
- Patients should be re-evaluated every 2 weeks if opioids are prescribed longer for acute pain
Providing patients with additional opioids in case they are needed should be avoided. Many patients do not use the full opioid prescription after surgery. Patients who need opioids for more than two weeks should be re-evaluated to reassess the acute pain and determine if there are additional underlying factors contributing to the pain.
Long-term opioid use requires follow-up
- Follow up with patients 1-4 weeks after initiation of long-term opioid therapy
- Shorter follow-up periods may be necessary for higher doses of opioids (>50 MME/day)
The risk of overdose within the first two weeks of long-term opioid therapy is greater in those with daily MME over 50. For this reason, patients initiating long-term opioid therapy should be re-evaluated within 1-4 weeks. Patient goals and long-term therapy plans should routinely be discussed at follow-up appointments.
Assessing risk and addressing potential harms of opioid use
- Screen for and discuss mental health disorders
- Naloxone should be offered to anyone receiving an opioid prescription
- Exercise caution when prescribing opioids in the elderly and those with renal or hepatic impairment
- Discuss risks of combining alcohol with opioid therapy
Assessing patients for mental health disorders, including anxiety, depression, and PTSD is important prior to prescribing opioid medications. Mental health conditions may predispose patients to a higher risk of opioid use disorder. Properly addressing mental health conditions may help improve long-term pain outcomes as alternative agents for depression or anxiety may also help improve pain, such as tricyclic antidepressants.
Medication accumulation is a strong possibility in those with renal or hepatic impairment as well as those over the age of 65. Use of opioids in these populations should be closely monitored as the risk of life-threatening respiratory depression or central nervous system depression is higher.
The pharmacist’s role in prescribing opioids
Pharmacists play a critical role in opioid stewardship and promoting appropriate and safe use of opioid therapy. By meticulously assessing risk, optimizing dosing, educating patients, and fostering collaborative, patient-centered care, pharmacists can significantly mitigate opioid-related harms without sacrificing effective pain relief.
Written by Patrick Welch, PharmD, BCACP
