Pain Management

New Thinking: Opioids as a Last Resort Only

Study connects poor outcomes to early opioid treatment.
By: | March 7, 2014

“Routine opioid use is strongly not recommended for treatment of non-severe acute pain (e.g., low back pain, sprains, or minor injury without signs of tissue damage),” states a new guideline. “For acute pain, there is quality evidence that other medications and treatments are at least equivalent if not superior and no quality published evidence an opioid is superior for treatment of acute pain. … Among trials for treatment of acute pain, ibuprofen was reportedly superior to codeine or acetaminophen for acute injuries including fractures.”

The recommendations are included in the American College of Occupational and Environmental Medicine’s updated Opioid Treatment Guideline published by the Reed Group. They are based on extensive research of studies by more than two dozen professionals.

The guidelines address acute pain (up to four weeks), sub-acute pain (one to three months), and chronic pain identified as more than three months.

For injured workers with acute pain, the authors suggest opioids may do more harm than good. “Quality evidence indicates safety profiles are considerably worse for opioids,” the report says. “Studies also demonstrate worse functional outcomes for patients treated early with opioids. … Prolonged use of opioids after an acute event has been associated with worse functional outcomes.”

When acute, severe pain cannot be controlled by NSAIDs or other means, the guideline suggests the “lowest effective dose of a short-acting opioid” be prescribed. Additionally, it states:

  • A morphine equivalent dose limit of 50 mg is recommended. Exceeding that should be based on documented need and increased surveillance for adverse effects. In fact, the researchers suggest that should also be the dose limit for patients with sub-acute and chronic pain.
  • Lower potency opioids are recommended when sufficient for pain relief and dispensing only quantities sufficient for the pain are recommended.
  • Prescription drug monitoring programs are recommended to be checked.
  • NSAIDs or acetaminophen should generally accompany an opioid prescription.
  • Opioids should be prescribed at night or while not working when possible due to risk of impairments and lost time from work.
  • It is recommended to taper off the opioid in one to two weeks.

Injured workers with a variety of comorbidities may be at elevated risk of adverse effects and even death. Additionally, “there are considerable drug-drug interactions that have been reported.” Therefore, “considerable caution is warranted” when considering prescribing an opioid for a variety of conditions, including chronic hepatitis and/or cirrhosis, coronary artery disease, severe obesity, dysrhythmias, cerebrovascular disease, orthostatic hypotension, asthma, recurrent pneumonia, thermoregulatory problems, advanced age, osteopenia, osteoporosis, water retention, renal failure, testosterone deficiency, erectile dysfunction, abdominal pain, gastroparesis, constipation, prostatic hypertrophy, oligomenorrhea, pregnancy, human immunodeficiency virus, ineffective birth control, herpes, allodynia, dementia, cognitive dysfunction and impairment, gait problems, tremor, concentration problems, insomnia, coordination problems, and slow reaction time.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected].

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