Themes that emerged from the review process included consideration of a nonopioid strategy before initiating an opioid. These might include pharmacologic interventions such as acetaminophen or a nonsteroidal anti-inflammatory for nociceptive pain, pregabalin, gabapentin, or other medication to manage neuropathic pain, or nonpharmacologic interventions such as heat, ice, or distraction. All of these should also be considered as adjuncts to minimize opioid dosing as well, said Dr. Nuckols, citing well-documented synergy with multiple modalities of pain treatment.
Careful patient selection is also key, said Dr. Nuckols. She noted that she asks herself, “How likely is this patient to get into trouble?” with inpatient opioid administration. A concept that goes hand-in-hand, she said, is choosing the appropriate dose and route.
Dr. Herzig picked up this theme, noting that route of administration matters. A speedy route, such as intravenous administration, has been shown to reinforce the potentially addictive effect of opioids. There are times when IV is the route to use, such as when the patient can’t take medication by mouth or when immediate pain control truly is needed. However, oral medication is just as effective, albeit slightly slower acting, she said.
Conversion from IV to oral opioids is a potential time for trouble, said Dr. Herzig. “Always use an opioid conversion chart,” she said. Cross-tolerance can be incomplete between opioids, so safe practice is to begin with about 50% of the OME dose with the new medication and titrate up. And don’t use a long-acting opioid for acute pain, she said, noting that not only will there be a long half-life and washout period if the dose is too high, but patient risk for later opioid use disorder is also upped with this strategy. “You can always add more, but it’s hard to take away,” said Dr. Herzig.
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