Opioids for Acute Pain: How Can We Prevent Harm?

Lesley Graham^1,2
Sylvia Hyland³
Beth Sproule^1,2,4
1 Centre for Addiction and Mental Health, Toronto, Ontario.
2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario.
3 Institute for Safe Medication Practices, Toronto, Canada.
4 Department of Psychiatry, University of Toronto, Toronto, Ontario.

Many assume that the short-term use of opioids for acute pain is reasonable and safe. Opioid stewardship activities have primarily focused on opioid use for chronic pain, however recent research has provided a robust evidence-base on the balance between benefits and harms of opioid use for acute pain. We now know that patients are receiving excessive quantities and doses of opioids for acute pain that can lead to harm (See Figure). Improving the safety of prescribed opioids continues to be an important harm prevention measure, especially in the context of the current opioid crisis.

Figure: Harms associated with excessive opioid quantities and doses for acute pain.

What do you think of the following prescriptions?

Rx 1

• 30 x acetaminophen 325mg / oxycodone 5mg tablets with directions to take one to two tablets every four to six hours when required for pain
• Patient: 16-year-old male, opioid naive, who has just undergone a routine wisdom tooth extraction.

Rx 2

• 60 x oxycodone 5mg tablets with directions to take one to two tablets every four to six hours when required for pain
• Patient: 53-year-old male, opioid naive, who has just undergone a cholecystectomy (gallbladder removal).

When reflecting on these prescriptions, here are key points to consider:

• Quantities of up to 20 tablets are sufficient for most indications (with the exception of a few major surgical procedures, see Best Practice in Surgery Guidelines (16))
• Maximum daily doses should not exceed 50 mg morphine equivalents (MME) in opioid naïve patients (17)
• Opioids are not indicated for pain after routine wisdom tooth extractions, unless alternatives are contraindicated or inadequate (however this is unlikely) (18, 19)
• Opioids are indicated if required for severe acute pain when alternatives are either inadequate or contraindicated (16)

Pharmacists are ideally placed to have a significant role to mitigate patient harm as they have the authority to dispense smaller quantities of medications including opioids (20) and can advise on safer daily doses of opioids. A series of eLearning modules and resources, based on the Health Quality Ontario (HQO) Standard for Opioids in Acute Pain (17), were developed to support pharmacists in this role. (Box 1)

The eLearning modules show how to apply this knowledge in practice using case studies, example questions and a demonstration of the language that could be used to suggest a smaller quantity, hold an opioid prescription or manage challenging questions from patients. Resources to support pharmacists in implementing these recommendations in a busy pharmacy include: a quick reference guidance document on choosing an appropriate quantity; the calculated number of tablets per day of opioid medications to stay within 50 MME; and a handout and poster for patients. The modules (Box 2) and resources were tested by community pharmacists and patients in Ontario during the development process and are freely available at the ISMP Opioids in Acute Pain website: https://www.ismp-canada.org/rxopioid/

This educational program was evaluated by surveying pharmacists in Ontario (n=182). Findings included:

• 94% of pharmacists reported that they gained knowledge and skills that were meaningful to their practice
• 85% reported that they would be able to apply what they had learned in practice.
• The percentage of pharmacists who knew the maximum daily dose of opioids increased from 56% to 100% before and after engaging with the modules (p < 0.001)
• The percentage of pharmacists who could recognize excessive quantities of opioids increased from 78% to 98% before and after engaging with the modules (p < 0.002)
• 90% of participants felt that it was their role to promote the safer use of opioids in acute pain
• Pharmacists who intended to offer part-fills increased from 26% in the pre-module group to 74% in the post-module group (p<0.001)

There is evidence linking the initiation of the opioid crisis to the increased availability of opioids over the course of the 2000s due to well-intentioned over-prescribing of opioids for chronic pain. (21) Opioid stewardship prevention measures complement the important treatment (e.g., opioid agonist therapy) and harm reduction initiatives (e.g., safer opioid supply programs) that also require pharmacist involvement to address the crisis.

Pharmacists are well positioned to help make opioid prescribing for acute pain safer, particularly as they serve as central points to partner with patients who may receive care from a range of prescribers. They also have the knowledge, skills and judgement to complete medication‐related therapeutic assessments and can make recommendations to patients regarding appropriate quantities and doses for initial opioid prescriptions for acute pain. Of note, OCP’s Opioid Policy (22) states that pharmacy practice should be in alignment with provincial and federal opioid strategies, including the HQO standards (17). Additionally, one of OCPs Quality Indicators is the percentage of patients who were newly dispensed an opioid prescription greater than 50 mg MME per day. (23) The eLearning modules and resources now available were designed to help support these best practices.

Funding provided by the Substance Use and Addictions Program, Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.

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