Date Reviewed | 19 February 2023 |
Subject | The Use of Opioids for Pain Control in Urgent Care |
Patient Population | Patients over 18 with an acute or chronic painful condition. Excludes patients with pain from sickle cell crisis, cancer pain, and palliative or end-of life care. |
Rationale | Patients will present to Urgent Care centers with painful conditions requiring medication for relief of pain. Not all patients will receive adequate pain control or will be able to tolerate acetaminophen or NSAIDs. Some patients will require treatment with opioids. The Urgent Care provider should be well versed in the indications, risks and benefits of treatment with narcotic pain relievers. |
Introduction | The over-prescription of opioids has led to a national opioid crisis. At its peak, the overuse of opioids was estimated to cost over $700 billion annually. State and federal agencies have introduced stricter guidelines to address the opioid crisis. Research published by the CDC determined that the dose and duration of the treatment represents an important factor leading to addiction. In this report, it was also suggested that a treatment as short as 10 days can lead to opioid dependency. Recent data also suggests that up to 15% of surgical patients may become dependent following the perioperative use of opioids. This re-enforces the recommendation limiting the amount of opioids used for acute pain, and endorses a multi-modal approach to the treatment of pain. The goal of acute pain management is to relieve suffering, facilitate function, enhance recovery, and satisfy patients. Pain control regimens must take into account medical, psychological, and physical condition; age; personal preference; and response to agents given. The optimal strategy for acute pain control should consist of multimodal therapy to increase efficacy, reduce side effects of therapy, and minimize the need for opioids. |
Evidence based guideline | Dowell D, Ragan KR, et. al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022, MMWR Recomm Rep 2022;71(No. RR-3): 1-95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1 |
Discussion | Patients present to Urgent Care with a wide variety of painful conditions requiring medication for pain control. Some conditions may be so severe that non-opioid treatments may not provide relief. These may include but are not limited to kidney stones, fractures, herpes zoster, and rib fractures. Other patients may not tolerate acetaminophen or NSAIDs due to allergy, gastric disorders including PUD, gastritis, and bariatric surgery, and renal disorders.
First line treatment for pain control should be non-pharmacologic management. This may include heat for soreness, ice for painful injuries, elevation, compression, and immobilization. Topical agents may have some effect for painful conditions and include topical diclofenac, lidocaine patches, menthol preparations, and capsaicin. Acetaminophen and NSAIDs should be tried first for pain. If one drug is ineffective, another should be tried as some patients find better relief from one NSAID over another. If unable to tolerate oral medications, acetaminophen may be given IV, and ketorolac may be given IV or IM.
Once it is determined that first line pain control methods are not appropriate, or have failed, and the patient is in moderate to severe pain, opioid pain relievers may be considered. Patients should be informed of the realistic expectations and the risks of opioid therapy, such as sedation, respiratory depression, pruritis, urinary retention, constipation, nausea, as well as longer term risks such as tolerance, dependence, withdrawal upon cessation of treatment and abuse. Patients need to have reasonable expectations; the goal is to make the pain tolerable, but not necessarily relieved.
Prescribers should review medical records to determine if the patient has had previous experience with narcotic medication, if they have risk factors for abuse, and if there are any other medications that may be a contraindication or increase risk for additive side effects.
If available, state databases should be consulted to identify any recent prescriptions or warning signs. All applicable state laws should be followed when prescribing controlled substances.
Patients with pre-existing opioid abuse disorders should be treated with non-opioid options or referred to pain management.
The lowest potency and the lowest dose possible that provides improvement in the patient’s pain should be prescribed. The goal should be to make the patient’s pain tolerable with the fewest side effects. Immediate release preparations should be used as initial therapy, not long acting. Only a several days supply should be provided, and the patient reassessed frequently. They should be switched to a non-opioid medication as soon as possible.
Upon completion of therapy, patient education should include tapering, if indicated, proper storage and disposal of unused medication. |
Summary | · Non-drug and non-opioid drug therapies should be maximized before initiating opioid therapy · Clinicians should discuss with patients the realistic benefits and known risks of opioid therapy · Immediate-release opioids, not long-acting, should be used for the initiation of opioid therapy · If opioid therapy is initiated, it should be at the lowest effective dose possible for the shortest amount of time · Patients should be reassessed within 1-4 weeks of initiation of opioids to evaluate risks and benefits of therapy · Each patient should be evaluated for the risk of opioid-related abuse and discuss the risk with patient before starting therapy. Patients should be re-evaluated periodically to ensure no abuse is occurring. · Prescribers should review the patient’s history of controlled substance prescriptions to ensure the patient is not receiving dosages or combinations that could result in overdose · Patients with pre-existing opioid abuse disorder should be treated with evidence-based medications or arrange treatment with specialty care |
References | Dowell D, Ragan KR, et. al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022, MMWR Recomm Rep 2022;71(No. RR-3): 1-95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1
Wardhan R, Chelly J. Recent advances in acute pain management: understanding the mechanisms of acute pain, the prescription of opioids, and the role of multimodal pain therapy. F1000Res. 2017 Nov 29;6:2065. doi: 10.12688/f1000research.12286.1. PMID: 29225793; PMCID: PMC5710326. |
Reviewers | Tracey Q. Davidoff, MD, FCUCM Sean McNeeley, MD, FCUCM |
