Appropriate Opioid Use
Chronic pain is often undertreated and can lead to disability, depression, and other problems.2,19,22 In recent years, there has been increasing focus on ensuring that patients get their pain addressed. The U.S. Joint Commission considers pain assessment to be a patient right, and in 1996 the American Pain Society pioneered the concept of pain as the 5th vital sign.21,22 Opioid marketing also became more aggressive.46 In Canada and the U.S., opioid prescribing doubled from the late 1990s to 2012.23,24 With increased opioid prescribing has come increased misuse and diversion.25,26,46 But things are changing. Centers for Medicare and Medicaid Services has proposed new pain management items on their Hospital Consumer Assessment of Healthcare Providers and Systems survey that focus on communication about pain, and will be removing the pain management dimension from the scoring formula used in the Hospital Value-Based Purchasing Program beginning with the fiscal year 2018 payment adjustments.48 And recent opioid guidelines emphasize functional goals, not just pain relief.31,46 Opioid prescribing in the U.S. seems to be plateauing or even decreasing based on data from 2011 to 2013.20 This may be due to prescribing restrictions, education, prescription monitoring programs, and prescribing of abuse-deterrent formulations.20,30 From 2003 to 2014, there was a moderate reduction in opioid prescribing among Ontario Public Drug Program beneficiaries, but no change in rates of opioid-related overdose or high-dose opioid prescribing, and opioid-related hospital visits continued to increase.46 In 2014, Canada’s National Anti-Drug Strategy expanded to include prescription drug misuse, and new guidelines were published in 2017 to promote evidence-based opioid prescribing for chronic noncancer pain.46 With careful patient selection, education, and monitoring, opioids can be safe and effective tools for management of chronic noncancer pain.2 This table provides resources to help clinicians managing chronic pain with opioids, one of the most challenging areas of clinical practice. Also check with your licensing body for information on state or provincial regulations pertaining to dosing limits, screening, monitoring, etc. For information specific to community pharmacy practice, get our PL CE, Ensuring Appropriate Opioid Management in a Community Pharmacy Setting (Pharmacists) (Pharmacy Technicians).
Abbreviations: ORT = Opioid Risk Tool; PTSD = post-traumatic stress disorder
Suggested Strategies or Resources
Limit opioid use for back pain.
Do not use opioids first-line for back pain.
See our PL Charts, Treatment of Acute Low Back Pain and Treatment of Chronic Low Back Pain, for preferred treatments. Use our PL Patient Education Handout, Back Pain Self-Care, for patient tips to treat and prevent back pain.
Limit opioid use for acute pain.
Adequate treatment of acute pain is important to prevent transition to chronic pain, but care should be taken to ensure that patients do not accidentally transition from using opioids for acute pain to prolonged use.4,47
Do not use opioids first-line for most kinds of acute pain.
State laws and/or payers (e.g., insurance companies, pharmacy benefit managers [PBMs]) are setting dose and/or quantity limits on opioid prescriptions.50
Prescribe the lowest effective dose.49
Prescribe only enough for the anticipated duration of severe pain (usually three to seven days), then re-evaluate.27,31
Advise patients to wean off the opioid to over-the-counter (OTC) acetaminophen or NSAIDs as their pain resolves.1
Do not prescribe extended-release opioids for acute pain.1
See our PL Chart, Analgesics for Acute Pain, for preferred treatments.
Identify appropriate/inappropriate uses for chronic opioids.
Chronic opioids are most appropriate for patients with moderate to severe pain unresponsive to non-opioids (e.g., acetaminophen or NSAIDs for osteoarthritis, tricyclics or anticonvulsants for neuropathic pain).2,3,46
Generally avoid opioids in pelvic pain, fibromyalgia, headaches, migraine, low back pain, temporomandibular disease, irritable bowel syndrome, ill-defined pain syndromes, and situations where secondary gain (e.g., money) or psychosocial factors are in play.2,4,18
Identify patients at risk for opioid misuse.
Screen for opioid abuse risk factors: younger age, history of psychiatric illness, personal or family history of substance abuse.2,4
Be wary of patients insisting on specific products or claiming allergies to specific analgesics; this is a red flag for drug-seeking behavior.15 Use our PL Algorithm, Opioid Intolerance Decision Algorithm, to help find the best options for potentially allergic patients.
Risk assessment tools such as ORT (Opioid Risk Tool), SOAPP-R (Screener and Opioid Assessment for Patients with Pain, revised), and DIRE (Diagnosis, Intractability, Risk, Efficacy) are available at http://www.opioidrisk.com/node/3310. However, available evidence suggests these tools are not very accurate in distinguishing low-risk from high-risk patients.31 Other tools identified in the Canadian guideline include CAGE (for alcohol) and the Current Opioid Misuse Measure.46
In the U.S., check your state’s prescription drug monitoring program to identify patients who may be improperly using or diverting opioids and other controlled substances, or getting a benzo prescription from another prescriber. In Canada, use your provincial drug information system or prescription monitoring program, if available.
To prevent misuse and diversion of controlled substance prescriptions, it’s important to watch for “red flags.” For examples, see our PL Detail-Document, "Red Flags": Tips for Appropriate Dispensing of Controlled Substances (U.S.).
Reduce risk of overdose.
Screen for depression, suicidal ideation, and other mental health problems.4,46
For persistent pain in patients with a history of substance use disorder or an active psychiatric disorder, it is suggested that optimized non-opioids be continued, rather than attempting an opioid trial.46
Avoid opioids in patients with active substance use disorder, including alcohol.46
Prescribe/dispense opioids in small quantities to at-risk patients.4
Keep in mind that women are at higher risk of overdose than men.5
If possible, avoid other respiratory/central nervous system depressants (e.g., benzodiazepines, barbiturates, diphenhydramine, muscle relaxants, promethazine).5,6,12,13
Start with a low dose of a short-acting opioid (e.g., oxycodone 5 mg every 4 to 6 hours as needed).4,13 Reserve long-acting opioids for select patients.
Try to avoid combining short- and long-acting opioids.31 Some long-acting formulations can be given more frequently if breakthrough pain consistently occurs toward the end of the dosing interval. For example, MS Contin or OxyContin may be dosed every eight hours, or Duragesic every 48 hours.41-45
Consider the partial opioid agonist buprenorphine for patients who need an opioid for chronic pain, but for whom an opioid with a wider margin of safety than full agonists is desirable. Our PL Chart, FAQs About Buprenorphine for Chronic Pain, provides an overview of this opioid that is unfamiliar to many clinicians.
Limit the initial opioid trial to oral morphine 50 mg daily, or its equivalent.46
Be aware that overdose risk increases significantly at doses of oral morphine >100 mg daily, or its equivalent.11,a The CDC recommends careful reassessment of benefits and risks before increasing the daily dose to ≥50 mg morphine or its equivalent (e.g., hydrocodone 50 mg [U.S.], hydromorphone 10 mg, or oxycodone 30 mg).31,46 Avoid increasing the dose daily to ≥90 mg morphine or its equivalent without careful justification.31,46
A trial of a different opioid (opioid rotation) can be considered for uncontrolled pain, to improve pain and function.46
Dose methadone safely. Methadone safety guidelines can be found at http://www.jpain.org/article/S1526-5900(14)00522-7/pdf. These guideline and more are reviewed in our PL Chart, Methadone for Pain: Focus on Safety.
Advise patients/caregivers to hold the dose and contact the prescriber in the event of respiratory depression or somnolence.
Use caution when switching between opioids. See our PL Chart, Equianalgesic Dosing of Opioids for Pain Management, for help.
Ensure that patients and caregivers understand not to break, split, or crush sustained-release formulations. Specific cautions and patient counseling points are available in our PL Chart, Abuse-Deterrent Opioids.
See “Naloxone” section, below.
Consider naloxone for patients with risk factors for overdose (e.g., high dose, switching from one opioid to another, history of overdose or substance abuse, etc).14
The AMA has helpful tips for selecting patients who could benefit from a naloxone prescription at http://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/co-branded-naloxone.pdf.
Learn more about naloxone in our PL Chart, Naloxone for Opioid Overdose: FAQs, and in our PL CE LIVE: Special Edition: Overdose Prevention with Naloxone, archived webinar.
Information about naloxone of specific interest to pharmacists is available in or PL CE, Naloxone Rescue Therapy for Opioid Overdose.
U.S.: Information on preparing and prescribing naloxone rescue kits is available at www.prescribetoprevent.org.
With permission from the Prescribe To Prevent group, prescription forms with tear-off patient instructions are being made available to subscribers of Pharmacist’s Letter/Prescriber’s Letter: Naloxone for Overdose Prevention (intramuscular) and Naloxone for Overdose Prevention (intranasal).
In Canada, refer to federal, provincial, and territorial programs. The College of Pharmacists of British Columbia has additional resources, including patient handouts, at http://www.bcpharmacists.org/naloxone.
Manage patient expectations.
Set goals with the patient for functional improvement, and document them for future monitoring purposes; this is how efficacy will be determined.4
Explain that improving pain and function by about 30% is a success.4,31
Explain that evidence of long-term benefit is lacking.16
Think SMART: the goals should be Specific, Measurable, Action-oriented, Realistic, and Time-dependent.32
View the opioid prescription as a time-limited trial; you are testing benefit to the patient, not committing to long-term opioid use.32
Educate patients about opioid safety.
An educational poster from the CDC promoting non-opioid alternatives is available at http://www.cdc.gov/drugoverdose/pdf/guidelines_patients_poster-a.pdf.
A patient fact sheet from the CDC discussing opioid risks, opioid alternatives, and measures to improve opioid safety is available at http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-patients-a.pdf.
ISMP Canada provides information to consumers on safe medication use including opioids https://www.safemedicationuse.ca/tools_resources/tips.html.
Patient counseling should include advice to avoid driving during dose increases or if they are sedated. Patients should be told to avoid using alcohol or sedating drugs. If they do, they should not drive.4
Patients should be counseled on how to safely store and dispose of opioids.5 Treatment agreements often include an expectation of secure storage.
Apprise patients of the risks of chronic opioid use, including hypogonadism, sleep apnea, tolerance, hyperalgesia (i.e., pain sensitization caused by chronic opioid use), withdrawal, and addiction, at baseline and periodically.2,13,28,46
Prevent and identify misuse.
Consider a treatment agreement, at minimum, for patients at high risk of misuse, or patients not well known to the prescriber. Some experts feel that a treatment agreement is needed for all patients receiving opioids for chronic noncancer pain.5 See our PL Detail-Document, Opioid Treatment Agreements, for more information, including links to sample agreements.
Require in-person follow-up in order for patients to obtain a refill or new prescription.
Consider pill counts.32
Consider urine drug testing.
Consider abuse-deterrent formulations. Our PL Chart, Abuse-Deterrent Opioids, describes the deterrent mechanism and precautions/counseling points for each formulation. Keep in mind these products have not been proven to prevent opioid misuse.
Pharmacists can get our PL CE, The Balancing Act with Controlled Substances: Ensuring Access for Patients with Valid Prescriptions, to learn what they can do to help keep controlled substances out of the wrong hands, while ensuring safe access for patients with legitimate need.
Ensure appropriate follow-up and evaluation of opioid therapy.
Schedule follow-up every one to four weeks while determining the optimal dose.4,17 Treatment agreements generally require in-person follow-up in order for patients to obtain a refill or new prescription.
Chronic pain is often accompanied by impaired function, multiple medical conditions, and psychological disorders.2 Address these areas in addition to evaluation of efficacy (i.e., improved function and pain control), adverse effects, and evidence of misuse.4
The two-item version of the Graded Chronic Pain Scale is available at http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf (See Figure B). It measures pain intensity and related disability.
Canadian opioid management tools and guidelines are available at http://nationalpaincentre.mcmaster.ca/guidelines.html and https://thewellhealth.ca/cncp.
Consider re-evaluation of therapy before increasing the daily dose to 50 mg of oral morphine or its equivalent, and again before increasing the dose to 90 mg of morphine or its equivalent.31,a
Use appropriate non-opioid and adjunctive therapies.
Maximize dosing of non-opioid pain medications before opioids are used.2,3
Integrate interdisciplinary therapy. This usually involves exercise and psychological therapy.2
In addition, proper sleep hygiene is recommended.13
To prevent constipation, prescribe an osmotic laxative (PEG 3350, etc) or a stimulant laxative with opioids.29 Fluids, fiber, and exercise can also be recommended.8,29
Ensure associated comorbidities are treated (e.g., depression, obesity).
Taper dose or discontinue opioids when appropriate.
If misuse occurs, evaluate whether continuation of chronic opioid therapy is appropriate. Restructuring of therapy (e.g., more intensive monitoring, opioid tapering, addition of non-opioid or psychiatric treatment) or referral may be indicated.2
Consider dose reduction or tapering and discontinuation in the event of inefficacy, intolerable side effects, signs of intoxication, overdose, evidence of diversion, or suspected hyperalgesia.2,9,10 Alternatively, rotation to another opioid could be attempted in case of inefficacy or side effects, or to facilitate dose reduction.46
When talking to patients about opioid discontinuation, explain that:
Multidisciplinary care (e.g., primary care physician, psychiatrist, addiction specialist, psychologist, pharmacist, physical therapist) is recommended for patients having problems with tapering, or if tapering unmasks a substance use or other psychological disorder.46
For more practical information on this topic, and additional tapering protocols, see our PL Chart, Opioid Discontinuation: FAQs.
Offer treatment for opioid use disorder.
Medication-assisted treatment of opioid use disorder has the most evidence and helps prevent withdrawal symptoms, decreases rates of illicit opioid use, reduces criminal activity, and improves social function.36,37
Our PL Chart, Management of Opioid Dependence, covers common clinical questions about approved medication-assisted treatments for opioid use disorder, with a focus on buprenorphine/naloxone.
In Canada, consult federal-, provincial-, and territorial-funded programs.
Manage opioids appropriately in the inpatient setting, including discharge.
In the emergency department (ED), urgent care, or at discharge:
See the 2018 Hospital Joint Commission Standards Pain Management for inpatient and discharge requirements: https://www.jointcommission.org/assets/1/18/Joint_Commission_
Continue any long-term, pre-op opioids in most surgical patients to avoid opioid withdrawal during hospitalization.38
Our PL Chart, Management of Opioid Dependence, includes tips on managing acute pain in hospitalized patients taking methadone or buprenorphine for opioid use disorder.
Don’t assume all post-op patients require opioids.38
Use multimodal analgesia (e.g., scheduled acetaminophen or an NSAID; gabapentin or pregabalin [e.g., gabapentin 600 to 1200 mg or pregabalin 150 to 300 mg one to two hrs pre-op] local or regional anesthesia; TENS) for its opioid-sparing effects perioperative opioid use is associated with subsequent long-term opioid use.38
Use oral opioids as opposed to intravenous opioids when possible.38 If this is not possible, use patient-controlled analgesia (PCA)(without a basal setting in opioid-naïve patients).38
Patients who are not on opioids chronically, but who are prescribed them post-op, can be told to taper their dose by 20% to 25% each day or every other day once pain is improving.38
Also instruct patients on disposing any leftover doses.27,38 Share our PL Patient Education Handout, Medication Disposal Guide, to help explain the disposal options in the U.S.
Where permitted by law, ensure appropriate use of medical marijuana for pain.
See the College of Family Physicians of Canada’s preliminary guidance on cannabis use for chronic pain at http://www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20
- See our PL Chart, Equianalgesic Dosing of Opioids for Pain Management.
Project Leader in preparation of this PL Detail-Document (320501): Melanie Cupp, Pharm.D., BCPS (last modified September 2017)
- Physicians for Responsible Opioid Prescribing (PROP). Cautious, evidence-based opioid prescribing. 2011. http://www.supportprop.org/educational/PROP_OpioidPrescribing.pdf. (Accessed April 11, 2016).
- Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-30.
- Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. Gen Hosp Psychiatry 2009;31:206-19.
- National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Part B. Recommendations for practice. April 30, 2010. http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf. (Accessed June 8, 2017).
- Centers for Disease Control and Prevention. Prescription painkiller overdoses. July 2013. http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/. (Accessed April 11, 2016).
- Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain 2014;15:321-7.
- University of British Columbia. Squire P, Jovey R. Managing opioid withdrawal-information for patients. 2013. http://med-fom-tcmp.sites.olt.ubc.ca/files/2014/06/For-Patients-TCMP-2014-Managing-Opioid-Withdrawal.pdf. (Accessed April 12, 2016).
- National Institutes of Health. National Cancer Institute. Gastrointestinal complications. Constipation. Updated January 4, 2016. http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications
/HealthProfessional/page2. (Accessed April 12, 2016).
- Silverman SM. Opioid induced hyperalgesia: clinical implications for the pain practitioner. Pain Physician 2009;12:679-84.
- Berland D, Rodgers P. Rational use of opioids for management of chronic nonterminal pain. Am Fam Physician 2012;86:252-8.
- Melville NA. Would daily opioid dose limits prevent overdose? Medscape Medical News. Conference News. September 16, 2013. http://www.medscape.com/viewarticle/811088#1. (Accessed April 11, 2016).
- Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology 2014;83:1277-84.
- Washington State Agency Medical Directors Group. Interagency guideline on prescribing opioids for pain. 3rd edition, June 2015. http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf. (Accessed March 11, 2016).
- U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. SAMHSA opioid overdose toolkit: information for prescribers. http://store.samhsa.gov/shin/content//SMA13-4742/Toolkit_Prescribers.pdf. (Accessed April 11, 2016).
- PL CE, Stemming the Tide: Stopping Prescription Opioid Diversion. Volume 2014, Course No. 228. Self-Study Course #14-228.
- Chou R, Deyo R, Devine B, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.). AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2014. http://www.effectivehealthcare.ahrq.gov/ehc/products/557/1971/chronic-pain-opioid-treatment-report-141007.pdf. (Accessed April 11, 2016).
- Nuckols TK, Anderson L, Popescu I, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med 2014;160:38-47.
- Kahan M, Mailis-Gagnon A, Wilson L, Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 1: general population. Can Fam Physician 2011;57:1257-66.
- Zorba Paster R. Chronic pain management issues in the primary care setting and the utility of long-acting opioids. Expert Opin Pharmacother 2010;11:1823-33.
- Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med 2015;372:241-8.
- Joint Commission. Speak up. Know your rights. http://www.jointcommission.org/assets/1/6/Know_Your_Rights_brochure.pdf. (Accessed April 11, 2016).
- National Pharmaceutical Council, Inc. Pain: current understanding of assessment, management, and treatments. December 2001. http://www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf. (Accessed April 11, 2016).
- Silversides A. Regulatory colleges to set painkiller guidelines. CMAJ 2009;181:464-5.
- CDC. Prescription drug abuse and overdose: public health perspective. October 24, 2012. http://www.cdc.gov/primarycare/materials/opoidabuse/docs/pda-phperspective-508.pdf. (Accessed April 11, 2016).
- Kraman P. Drug abuse in America-prescription drug diversion. April 2004. The Council of State Governments. http://www.csg.org/knowledgecenter/docs/TA0404DrugDiversion.pdf. (Accessed April 11, 2016).
- U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality. Results from the 2013 National Survey on Drug Use and Health: summary of national findings. http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/
NSDUHresults2013.pdf. (Accessed April 11, 2016).
- Massachusetts Hospital Association Substance Use Disorder Prevention and Treatment Task Force. Massachusetts Hospital Association guidelines for emergency department opioid management –executive summary and table of contents. https://www.mhalink.org/AM/Template.cfm?Template=/CM/ContentDisplay.cfm&ContentID=72155&FusePreview=True&WebsiteKey=a3f1fffe-a9f6-4b95-a06a-a551e90c7801. (Accessed April 13, 2016).
- Chou R. 2009 clinical guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: what are the key messages for clinical practice? Pol Arch Med Wewn 2009;119:469-77.
- PL Detail-Document, Treatment of Constipation in Adults. Pharmacist’s Letter/Prescriber’s Letter. June 2015.
- Cicero TJ, Ellis MS. Abuse-deterrent formulations and the prescription opioid abuse epidemic in the United States: lessons learned from OxyContin. JAMA Psychiatry 2015;72:424-30.
- Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep 2016;65:1–49.
- Alford DP, Liebschutz J, Jackson A, Siegel B. Prescription drug abuse: an introduction. Massachusetts NIDA Consortium. Boston University School of Medicine. http://www.powershow.com/view/3c50b3-MTExN/Prescription_Drug_Abuse_An_Introduction_Massachusetts
_NIDA_Consortium_powerpoint_ppt_presentation. (Accessed April 11, 2016).
- Saskatoon City Hospital. Rx Files. Opioid tapering. July 2014. http://www.rxfiles.ca/rxfiles/uploads/documents/Opioid-Taper-Template.pdf. (Accessed April 12, 2016).
- Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc 2015;90:828-42.
- Harden P, Ahmed S, Ang K, Wiedemer N. Clinical implications of tapering chronic opioids in a veteran population. Pain Med 2015;16:1975-81.
- Soyka M. New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone. Subst Abuse Rehabil 2015;6:1-14.
- SAMHSA. Medication-assisted treatment. Medication and counseling treatment. Updated September 28, 2015. http://www.samhsa.gov/medication-assisted-treatment/treatment. (Accessed April 12, 2016).
- Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016;17:131-57.
- WV Hospital Association. Press release. West Virginia Hospital Association announces guidelines for use and prescribing of opioids in hospital emergency departments. December 14, 2015. . http://www.wvha.org/getmedia/c5a47c54-7409-4b23-9bfc-751b45fc2648/FINAL-Press-Release-Opioid-Guidelines_1.pdf.aspx. (Accessed April 13, 2016).
- Ray WA, Chung CP, Murray KT, et al. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA 2016;315:2415-23.
- Product information for Duragesic. Janssen Pharmaceuticals. Titusville, NJ 08560. April 2014.
- Product monograph for Duragesic. Janssen. Markham, ON L3R 0T5. April 2017.
- Product information for MS Contin. Purdue Pharma. Stamford, CT 06901. June 2014.
- Product monograph for MS Contin. Purdue Pharma. Pickering, ON L1W 2A8. August 2014.
- Marcus DA, Glick RM. Sustained-release oxycodone dosing survey of chronic pain patients. Clin J Pain 2004;20:363-6 [abstract].
- Busse J, ed. The 2017 Canadian guideline for opioids for chronic non-cancer pain. http://nationalpaincentre.mcmaster.ca/documents/Opioid%20GL%20for%20CMAJ_01may2017.pdf. (Accessed June 8, 2017).
- Donnelly AJ, Golemniewski JA, Rakic AM. Perioperative care. In: Alldredge BK, Corelli RL, Ernst ME, et al, editors. Koda-Kimble & Young’s Applied Therapeutics: the Clinical Use of Drugs. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2013:147-74.
- Hospital Consumer Assessment of Healthcare Providers and Systems. What’s new. http://www.hcahpsonline.org/WhatsNew.aspx. (Accessed June 14, 2017).
- Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain – United States, 2016. March 2016. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. (Accessed September 11, 2017).
- ACP Internist. Opioid prescribing: states aim to limit opioid prescriptions. October 2016. https://acpinternist.org/archives/2016/10/laws.htm. (Accessed September 8, 2017).
- Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Database Syst Rev 2013;6:CD010210.
Cite this document as follows: PL Detail-Document, Appropriate Opioid Use. Pharmacist’s Letter/Prescriber’s Letter. May 2016.
- Be Aware of New Limits on First-Time Opioid Prescriptions
- Avoid Using Opioids and Benzodiazepines Together
- Don't Use a Long-Acting Opioid for Initial Therapy
- Limit Opioids for Acute Pain...to Decrease Risk of Long-Term Use
- Don't Jump to <em>Belbuca</em> Before Non-Opioids for Chronic Pain
- Prescribe Naloxone to Save a Life During Opioid Overdose
- Keep in Mind NSAIDs Work as Well as Opioids for Most Acute Injuries
- Try an NSAID Instead of Opioids for Chronic Musculoskeletal Pain