Opioid Prescribing for Acute Pain

Care for People 15 Years of Age and Older

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Comprehensive Assessment
People with acute pain receive a comprehensive assessment to guide pain management.

Quality Statement 2: Multimodal Therapies
People with acute pain receive multimodal therapy consisting of non-opioid pharmacotherapy with physical and/or psychological interventions, with opioids added only when appropriate.

Quality Quality Statement 3: Opioid Dose and Duration
People with acute pain who are prescribed opioids receive the lowest effective dose of the least potent immediate-release opioid. A duration of 3 days or less is often sufficient. A duration of more than 7 days is rarely indicated.

Quality Statement 4: Information on Benefits and Harms of Opioid Use and Shared Decision-Making
People with acute pain and their families and caregivers receive information about the potential benefits and harms of opioid therapy, safe storage, and safe disposal of unused medication at the times of both prescribing and dispensing.

Quality Statement 5: Acute Pain in People Who Regularly Take Opioids
People with acute pain who regularly take opioids receive care from a health care professional or team with expertise in pain management. Any short-term increase in opioids to treat acute pain is accompanied by a plan to taper to the previous dose.

Quality Statement 6: Acute Pain in People With Opioid Use Disorder
People taking buprenorphine/naloxone or methadone for the treatment of opioid use disorder continue their medication during acute-pain events.

Quality Statement 7: Prescription Monitoring Systems
Health care professionals who prescribe or dispense opioids have access to a real-time prescription monitoring system at the point of care. Prescription history is checked when opioids are prescribed and dispensed to avoid duplicate prescriptions, potentially harmful medication interactions, and diversion.

Quality Statement 8: Tapering and Discontinuation
People prescribed opioids for acute pain are aware of the potential for experiencing physical dependence and symptoms of withdrawal and have a plan for tapering and discontinuation.

Quality Statement 9: Health Care Professional Education
Health care professionals have the knowledge and skills to appropriately assess and treat acute pain using a multimodal approach; appropriately prescribe, monitor, taper, and discontinue opioids; and recognize and treat opioid use disorder.

Resources Quality Statements Advisory Committee About

Opioid Dose and Duration

People with acute pain who are prescribed opioids receive the lowest effective dose of the least potent immediate-release opioid. A duration of 3 days or less is often sufficient. A duration of more than 7 days is rarely indicated.

Background

For people in an outpatient or primary care setting who have not consumed opioids recently, opioids prescribed for acute pain should be prescribed for only short-term use at the lowest effective dose. Opioid use for acute pain is associated with a risk of long-term opioid use; factors associated with the sharpest increase in long-term use include an initial 10-day supply, more than 5 days of use, and a second prescription or refill.

The maximum daily oral dose recommended for people with acute pain who do not regularly take opioids, based on risk of overdose or death, is a dose equivalent to 50 mg of morphine. Expert opinion suggests a duration of 3 days or less is sufficient in most cases of acute pain seen in primary care. Methadone, fentanyl or buprenorphine patches, and extended-release versions of other oral opioids are not recommended for the treatment of acute pain because of their increased risk of harm owing to longer half-lives and longer duration of action. Physical dependence is an expected physiologic response in people exposed to opioids for more than a few days; therefore, lowering the number and potency of doses prescribed should minimize the need to taper opioids to prevent withdrawal symptoms and reduce the quantity of prescribed opioids available for diversion in the community.

One reason postoperative prescriptions are often written for 7 days or longer is that it can be difficult to estimate the duration of opioids required. However, clinicians should not prescribe additional doses to patients “just in case” pain continues for longer than expected. Prescribing for a duration of more than 7 days, or providing a refill or second prescription, has been associated with approximately double the likelihood of continued use 1 year later. Only in rare or exceptional cases is a supply of opioids for more than 7 days appropriate. If a longer duration of prescription is warranted, health care professionals may consider the use of a partial refill after 7 days if acute pain continues.

If acute pain continues for longer than expected, health care professionals should reassess the person to confirm or revise the initial diagnosis and adjust the pain management plan. If pain persists, health care professionals should consider other conditions, including opioid use disorder, and consult with other relevant health care professionals involved in the treatment of the person’s pain.

What This Quality Statement Means

For Patients

If you are prescribed opioids, your health care professional should prescribe the lowest dose and lowest strength that will work for you. If you are seeing your family doctor, dentist, or nurse practitioner outside the hospital, in most cases, your prescription should be for 3 days or less. More severe acute pain, such as pain from major surgery, may require a longer prescription. Your health care professional should monitor your pain and help you to stop taking opioids when your pain is reduced.

When your pharmacist gives you opioids, they should explain to you how to safely store your medication and how to safely dispose of any unused medication you no longer need.

For Clinicians

For acute pain, prescribe the lowest effective dose of the least potent immediate-release opioid. A duration of 3 days or less is often sufficient; more than 7 days is rarely indicated.

For Health Services

Ensure that policies and protocols are developed and implemented to encourage low-dose and limited-duration opioid prescriptions for acute pain. Ensure timely follow-up is available to people with acute pain continuing past 7 days.

Quality Indicators

Process Indicators

Percentage of people with acute pain prescribed an opioid who were prescribed an initial dose greater than 50 mg morphine equivalents per day

Denominator: total number of people with acute pain who were prescribed an opioid and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator who were prescribed an initial dose greater than 50 mg morphine equivalents per day
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System

Percentage of people with acute pain prescribed an opioid who are prescribed no more than a 3-day supply

Denominator: total number of people with acute pain who are prescribed an opioid and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator whose prescription is for no more than a 3-day supply
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System

Percentage of people with acute pain prescribed an opioid who are prescribed more than a 7-day supply

Denominator: total number of people with acute pain who are prescribed an opioid and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator whose prescription is for more than a 7-day supply
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System

Percentage of people with acute pain prescribed an opioid whose prescription is for an extended-release opioid

Denominator: total number of people with acute pain who are prescribed an opioid and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator whose prescription is for an extended-release opioid
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System

Evidence to Improve Care