Table 2.

Society of Hospital Medicine Recommendations on Improving the Safety of Opioid Use for Acute Non-Cancer Pain in Hospitalized Adults Outside of Intensive Care, Palliative Care, and End-of-Life Care

Deciding Whether to Use Opioids During Hospitalization:

1. Limit the use of opioids to patients with 1) severe pain or 2) moderate pain that has not responded to non-opioid therapy, or where non-opioid therapy is contraindicated or anticipated to be ineffective.

2. Use extra caution when administering opioids to patients with risk factors for opioid-related adverse events.

3. Review the information contained in the prescription drug monitoring program (PDMP) database to inform decision-making around opioid therapy.

4. Educate patients and families/caregivers about potential risks and side effects of opioid therapy as well as alternative pharmacologic and non-pharmacologic therapies for managing pain.

Once a Decision Has Been Made to Use Opioids During Hospitalization:

5. Use the lowest effective opioid dose for the shortest duration possible.

6. Use immediate-release opioid formulations and avoid initiation of long-acting/extended-release formulations (including transdermal fentanyl) for treatment of acute pain.

7. Use the oral route of administration whenever possible. Intravenous opioids should be reserved for patients who cannot take food or medications by mouth, patients suspected of gastrointestinal malabsorption, or when immediate pain control and/or rapid dose titration is necessary.

8. Use an opioid equivalency table or calculator to understand the relative potency of different opioids 1) when initiating opioid therapy, 2) when changing from one route of administration to another, and 3) when changing from one opioid to another. When changing from one opioid to another, clinicians should generally reduce the dose of the new opioid by at least 25–50% of the calculated equianalgesic dose to account for inter-individual variability in the response to opioids as well as possible incomplete cross-tolerance.

9. Pair opioids with scheduled non-opioid analgesic medications, unless contraindicated, and always consider pairing with non-pharmacologic pain management strategies (i.e., multimodal analgesia).

10. Unless contraindicated, order a bowel regimen to prevent opioid-induced constipation in patients receiving opioids.

11. Limit co-administration of opioids with other central nervous system (CNS) depressant medications to the extent possible.

12. Work with patients and families/caregivers to establish realistic goals and expectations of opioid therapy and the expected course of recovery.

13. Monitor the response to opioid therapy, including assessment for functional improvement and development of adverse effects.

Prescribing at the Time of Hospital Discharge:

14. Ask patients about any existing opioid supply at home and account for any such supply when issuing an opioid prescription on discharge.

15. Prescribe the minimum quantity of opioids anticipated to be necessary based on the expected course and duration of pain severe enough to require opioid therapy after hospital discharge.

16. Ensure that patients and families/caregivers receive information regarding how to minimize the risks of opioid therapy for themselves, their families, and their communities. This includes but is not limited to: 1) how to take their opioids correctly (the planned medications, doses, schedule); 2) that they should take the minimum quantity necessary to achieve tolerable levels of pain and meaningful functional improvement, reducing the dose and/or frequency as pain and function improve; 3) how to safeguard their supply and dispose of any unused supply; 4) that they should avoid agents that may potentiate the sedative effect of opioids, including sleeping medication and alcohol; 5) that they should avoid driving or operating heavy machinery while taking opioids; and 6) that they should seek help if they begin to experience any potential adverse effects, with inclusion of information on early warning signs.