Manage Acute Pain in Those Using Opioids

APRIL 02, 2019
Siddharth Jain, PharmD Candidate; Bernice Lee; PharmD Candidate; and Deepali Dixit, PharmD, BCPS, BCCCP, FCCM
In the United States, opioid use has increased significantly over the past few decades, and according to the results of a 2013 CDC study, opioid abuse, misuse, and overdose cost about $78.5 billion annually.1

With the rise of opioid use, there has also been an increase in average opioid prescription duration and in opioid use for chronic pain management.2 Chronic pain is defined as pain that lasts beyond 3 months.3 As of 2009, about 3% of American adults used opioids regularly and about 1 of 4 patients prescribed opioids for chronic pain end up misusing them.4,5 This is a growing problem, because patients who chronically use opioids are at a higher risk of adverse events (AEs) and there is a need to address acute pain management in this population.6 Acute pain management requires a multimodal pain regimen and a multidisciplinary approach. The goals of treating acute pain in this population are to provide early adequate pain control with frequent dosage adjustments for suboptimal pain control, prevent withdrawal, and avoid triggering relapse or worsening addiction for those who have a history of substance use disorder.7

Initial Steps
Acute pain is generally defined as pain that lasts less than 3 to 6 months.8 For chronic pain patients, knowing the source of acute pain, whether it is an exacerbation of a known underlying pathological disorder, medical procedure, or a new condition, is an important distinction. Physical examination, relevant tests, and a review of the patient’s history must be conducted to ascertain the source of the acute pain. If the etiology of the acute pain is found to be separate from the patient’s chronic pain, the appropriate next step is to resolve the new condition, if possible. If the acute pain is found to be an exacerbation of the current condition, then the pain management therapy must be reevaluated.9,10

Strategies for Minimizing Opioid Use in Acute Pain 
Tolerance is frequent in patients on long-term opioids, and a widespread practice to improve analgesia in acute pain is to implement an opioid rotation protocol, increase the opioid dose, or introduce patient-controlled analgesia.11 For these patients, opioid-sparing techniques may play an important role to help limit the addition of more opioids to their regimen. By operating through separate pathways, combination therapy allows better control of pain with fewer AEs.12 Some opioid-sparing techniques include the use of multimodal analgesia by incorporating acetaminophen, antidepressants, cyclooxygenase-2 (COX2) inhibitors, gabapentinoids, intravenous (IV) lidocaine, ketamine, local anesthetics, and/or nonsteroidal anti-inflammatory drugs (NSAIDs).11

Acetaminophen, COX2 inhibitors, and/or NSAIDs can be given concomitantly with opioids, unless patients have a contraindication.13 Gabapentin and pregabalin are anticonvulsants proven to reduce opioid requirements and postoperative and neuropathic pain, respectively.14

Ketamine is an effective analgesic that does not cause hypotension or respiratory depression, and evidence shows that it can be useful for limiting acute pain in opioid-tolerant patients undergoing surgery.15 Local anesthetics, such as bupivacaine injections, EMLA cream, and lidocaine patches, work through multiple pathways and have analgesic and anti-inflammatory effects in acute and neuropathic pain. Topical applications, such as patches, can provide local analgesia for painful procedures, while site-specific local injections can provide nerve blocks that help manage postoperative pain, reducing the need for opioids.12,15 IV lidocaine may help suppress electrical activity pathways associated with pain, and its use has shown a decrease in nausea, opioid use, and vomiting.15 Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline), have shown analgesic properties in inflammatory, neuropathic, and nociceptive pain.12 Multimodal analgesia can be an effective tool to limit opioid use and maintain adequate control of acute pain.

Pharmacist's Role 
When dispensing opioids, pharmacists should monitor patients’ opioid therapy, as patients may see different prescribers for their acute and chronic pain management. Proper monitoring may prevent duplicate opioid therapy. For example, opioid therapy can be converted to the oral morphine equivalent (OME) to equalize dosage forms and potencies of different medications.16 Converting dosing to its OME is especially useful if patients rotate through several opioids. This can be used to mitigate AEs for chronic pain patients, such as minimizing potential withdrawal symptoms or inadvertent overdoses that can result from improper dose conversions.

Conclusion
Acute pain management in patients on chronic opioids requires obtaining a careful history and assessment of prior pain management strategies. Determining the etiology of the acute pain, implementing opioid rotation, and using a multimodal approach can help mitigate acute pain and
lower costs. By implementing various strategies, providers must work as a multidisciplinary team to minimize opioid use and AEs while ensuring proper care. Pharmacists play a vital role in managing pain regimens and ensuring proper compliance. 

 
Siddharth Jain and Bernice Lee are PharmD candidates at the Ernest Mario School of Pharmacy at Rutgers, the State University of New Jersey, in Piscataway.

Deepali Dixit, PharmD, BCPS, BCCCP, FCCM, is a clinical associate professor at the Ernest Mario School of Pharmacy and a clinical pharmacy specialist, critical care, at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.


References
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