Pharmacist-Led Pathways Help Health Systems Balance Opioid Stewardship and Acute Pain Relief

Opioid stewardship in acute pain care has commonly been associated with lowering opioid prescribing, although the reduction of exposure cannot be the sole goal. When opioids are required for acute pain, CDC guidance recommends prescribing no greater quantity than needed for the expected duration of pain severe enough to require opioids; however, stewardship efforts must also ensure that patients receive adequate analgesia and avoid preventable harm.¹

“Stewardship really is not about decreasing opioid prescribing alone,” said Tanya J. Uritsky, PharmD, BCPP, FPPCP, FASHP, opioid stewardship coordinator at the Hospital of the University of Pennsylvania and co-chair of the Penn Medicine Opioid Task Force, in an interview with Pharmacy Times. “Lowering the MME is important whenever possible or appropriate, but sometimes the consequence is patient harm and undertreated pain, which is not what we’re trying to do.”

According to Uritsky, successful opioid stewardship requires system-level approaches that support evidence-based multimodal analgesia while also incorporating harm-reduction strategies. These strategies may include access to naloxone, monitoring for patients who may be tapered too rapidly, and identifying patients who are admitted or readmitted because of pain.

“It’s also really important to include the patient's perspective,” Uritsky said. “We try and make sure we have a patient representative on our committees,” particularly when health-system efforts involve optimizing analgesia, reducing opioid exposure, or changing pain management practices.

Multimodal Pathways Require Standardization and Flexibility

Implementing consistent multimodal acute pain pathways can be challenging across large health systems, particularly when emergency, surgical, inpatient, ambulatory, and same-day surgery settings are all involved. Uritsky said one of the greatest barriers is the number of stakeholders who must be engaged.

“In our health system, we have 7 hospitals,” Uritsky said. “Getting everybody from each department on board that you need can be very challenging.”

Electronic health records can help support standardized care, but they can also create operational hurdles. Uritsky noted that clinicians at her institution can personalize their own notes, which made it difficult to embed prescription drug monitoring program documentation into standardized admission templates. However, EHR-integrated pathways have also been useful in guiding frontline care.

“There’s just not enough specialists to go around, and every patient experiencing pain cannot talk to a specialist,” Uritsky said. “We’re in a 1000-bed hospital, so it’s impossible.”

For patients with more complex pain management needs, such as those with opioid use disorder or sickle cell disease, Uritsky said evidence-based pathways can help standardize approaches and support clinicians who may not specialize in pain management.

Still, she emphasized that pathways should not function as rigid mandates.

“We do remind people, and we think it’s important always to remind people, that pathways are not policies,” Uritsky said. “They do allow room, and they should allow room, for clinical judgment.”

Outcomes Should Extend Beyond Opioid Use

While opioid consumption and morphine milligram equivalents remain important measures, Uritsky states hospitals need broader outcomes to determine whether acute pain programs are truly improving care. These may include patient experience, recovery time, return to function after surgery, length of stay, and risk of persistent opioid use.

“We do need more ways to get to the patient experience,” Uritsky said.

The HCAHPS survey replaced its original pain management questions with questions focused on communication about pain for patients discharged beginning January 1, 2018.² Uritsky said that change has made it harder for pain committees to capture standardized patient experience data around pain management. Her team uses Press Ganey reports to evaluate trends in patient experience, although she noted that those data are still not ideal.

“Return to function post-op is really important,” Uritsky said. “Of course, we need to provide analgesics, we need to provide pain medications for patients, but how are we doing as far as managing the acute pain period?”

Length of stay is also relevant, although Uritsky cautioned that it should be “right-sized” rather than reduced without regard for patient readiness.

“We do want to right-size that, but we, of course, don’t want to push people out too soon,” she said. “Looking for ways to get patients home and recovering more efficiently is really important for the patient.”

Opioid-Tolerant Patients Need Adequate Dosing, Multimodal Care

Patients who are opioid-tolerant or receiving medications for opioid use disorder, such as buprenorphine or methadone, may face elevated risk of undertreated pain, withdrawal, and stigma during acute pain episodes..¹

“These patients are super opioid tolerant,” Uritsky said. “That means that they’re not going to respond as well to opioids, and increasing the doses of opioids will have diminishing returns. It does not mean that they should not receive opioids.”

Instead, she said clinicians should ensure that multimodal analgesia is being used, including nonsteroidal anti-inflammatory drugs, acetaminophen, ketamine, and other appropriate options. Opioid-tolerant patients may also require higher opioid doses to achieve analgesia, although dose escalation should be balanced against diminishing returns.

“A lot of times we’re underdosing,” Uritsky said. “If the patient is really that tolerant, they need a higher dose in order to find an effect, but not escalating to crazy doses.”

Patients who are actively using illicit fentanyl may require additional monitoring for withdrawal, including withdrawal related to fentanyl and adulterants in the drug supply. CDC issued a 2025 Health Alert Network advisory describing severe illness linked to medetomidine exposure among patients using illicit substances, highlighting the increasingly complex drug supply clinicians may encounter.³

For patients receiving medications for opioid use disorder, Uritsky said clinicians should continue evidence-based treatment and consider pain-specific dosing strategies when appropriate.

“You can adjust the intervals for medications like buprenorphine and methadone so that they’re more frequent,” she said. “For analgesia, it might be reasonable to dose it every 8 hours, or even every 6 hours, to get more analgesic benefits.”

Standardized best practices, such as continuing buprenorphine during the acute pain period and using multimodal analgesia, can also help reduce the effect of stigma.

“By providing the best practices to folks, we can help reduce stigma,” Uritsky said. “Of course, it does not eliminate stigma, but it can decrease the impact of it.”

P&T Committees Evaluate Suzetrigine’s Place in Acute Pain Pathways

Newer nonopioid analgesics may offer additional options for multimodal acute pain management, but formulary decisions require careful evaluation. In January 2025, the FDA approved suzetrigine (Journavx; Vertex Pharmaceuticals) for the treatment of moderate to severe acute pain in adults, making it the first drug approved in a new class of pain management medicines.⁴

Uritsky said pharmacy and therapeutics committees may struggle with how to interpret clinical trial data for newer pain medications, particularly when studies are conducted in specific procedures.

“There’s a hang-up on the type of procedures that we use in order to get drugs approved,” Uritsky said. “The inclination is that, ‘Well, this was not studied in this procedure, so it doesn’t have a place in the treatment of that procedure.’”

However, she noted that procedures are often selected for acute pain trials because they produce a predictable level of moderate to severe pain.

“There’s no way that we can approve a drug and study every single procedure. It’s not possible,” she said.

Uritsky acknowledged that additional data are important, particularly for a new medication, but said committees may need to consider the severity and characteristics of the pain being studied rather than focus solely on the specific procedures included in pivotal trials.

“There’s also this very legitimate concern that once the drug is on formulary, the use will run rampant,” Uritsky said. “Once it’s on the formulary, it kind of bleeds out, and anybody can really access it.”

Prescribing information for suzetrigine includes considerations related to CYP3A interactions and hepatic impairment, and Uritsky said health systems must also evaluate efficacy, safety, cost, access, and real-world outcomes when determining how a new nonopioid analgesic fits within existing pathways.⁵

“That’s what matters most to the patients, right?” Uritsky said. “Does it work? Are they tolerating it OK? And can they afford it?”

Pharmacists Are Central to Acute Pain Stewardship

Improving acute pain care requires multiple interventions rather than a single solution. Uritsky said her health system uses pharmacist consultation, specialist pharmacists embedded in palliative care, addiction, and acute pain teams, standardized pathways, prescribing defaults, dashboard-guided academic detailing, discharge best-practice alerts, and standardized patient education.

“In my experience, moving the needle on improving care is really multifaceted,” Uritsky said. “It takes a lot of different approaches to provide holistic pain care.”

Electronic prescribing defaults have been one area of intervention. Uritsky said changes to opioid prescribing defaults resulted in a significant decrease in opioid prescribing. Researchers then texted patients to assess refill needs, pain severity, and remaining medication supply.

“Patients seemed to still have medications left, even after reducing our defaults,” Uritsky said. “So we determined we were not leaving patients without medication options, and that this was working effectively.”

Standardized pathways have also been valuable because they provide both clinical guidance and just-in-time education for frontline clinicians.

“It really does marry the 2 critical elements of standardization of best practices and education,” Uritsky said.

Despite competing priorities and limited resources, Uritsky emphasized that pharmacists should be integrated into acute pain care and stewardship efforts.

“In order to optimize your approaches, you do need the pharmacist to bring that element into the decision-making,” she said, adding that pharmacists help ensure interdisciplinary stakeholders are “coming together to make these decisions.”

References

1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. 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

2. Centers for Medicare & Medicaid Services. HCAHPS Update Training. March 2018.https://hcahpsonline.org/globalassets/hcahps/training-materials/2018_training-materials_slides_update.pdf

3. Centers for Disease Control and Prevention. Severe Illness Potentially Associated With Medetomidine Exposure Among Persons Who Use Illicit Substances. https://www.cdc.gov/han/php/notices/han00527.html

4. FDA. FDA Approves Novel Non-Opioid Treatment for Moderate to Severe Acute Pain.https://www.fda.gov/news-events/press-announcements/fda-approves-novel-non-opioid-treatment-moderate-severe-acute-pain

5. Vertex Pharmaceuticals. JOURNAVX (suzetrigine) prescribing information. https://pi.vrtx.com/files/uspi_suzetrigine.pdf