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Evidence to Improve Care

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 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.


Summary

This quality standard provides guidance on the appropriate prescribing, monitoring, and tapering of opioids to treat acute pain for people 15 years of age and older in all care settings. It does not address opioid prescribing for chronic pain or end-of-life care, nor does it address the management of opioid use disorder in depth.

Please refer to Health Quality Ontario’s Opioid Prescribing for Chronic Pain quality standard and Opioid Use Disorder quality standard for detailed quality statements related to these topics.


This quality standard provides guidance on the prescribing, monitoring, and tapering of opioids to treat acute pain for people aged 15 years of age and older in all care settings. It does not address opioid prescribing for chronic pain or end-of-life care, nor does it address the management of opioid use disorder in depth.

Please refer to Health Quality Ontario’s Opioid Prescribing for Chronic Pain quality standard and Opioid Use Disorder quality standard for detailed quality statements related to these topics.

The Opioid Prescribing for Acute Pain Quality Standard Advisory Committee agreed that it is important to include adolescents between 15 and 17 years of age in the scope of this quality standard because of the increased risk of harm opioids pose to this population. Adolescents report higher rates of nonmedical opioid use and intentional poisonings, and suffer a disproportionately higher rate of opioid-related deaths than the general adult population. These higher rates of harm stress the importance of providing guidance on the careful and appropriate prescribing of opioids for acute pain in youth.

While the scope of this quality standard includes adolescents between 15 and 17 years of age, it should be noted that the statements in this standard are based on guidelines whose evidence is derived primarily from studies conducted on adult (aged 18 years and older) populations. Health Quality Ontario’s Opioid Prescribing for Acute Pain Quality Standard Advisory Committee members agreed that the guidance in this quality standard is equally relevant and applicable to people between 15 and 17 years of age. However, health care professionals should take into account that specialized skills and expertise may be required when providing treatment for special populations, including adolescents with acute pain for whom opioid therapy has been prescribed or is being considered. If treatment of this or other special populations is beyond a health care professional’s expertise, the health care professional should consult or work with a health care professional with appropriate expertise.

This quality standard includes 9 quality statements addressing areas identified by Health Quality Ontario’s Opioid Prescribing for Acute Pain Quality Standard Advisory Committee as having high potential for improving the quality of care in Ontario for people with acute pain who have been prescribed or are considering opioids.

In this quality standard, the term “health care professional” is used to acknowledge the wide variety of providers who can be involved in the care of people with acute pain. The term refers to physicians, nurse practitioners, nurses, dentists, pharmacists, and other health professionals involved in the assessment, monitoring, and treatment of acute pain.

The term “prescriber” refers to physicians, nurse practitioners, and dentists who are authorized to prescribe opioids.

Acute pain is typically a normal, predicted response to surgery, acute illness, trauma, or other injury. It is recent in onset and is a self-limiting process that generally lasts from hours to days or a month after the precipitating event. The duration of acute pain is associated with the time it normally takes for healing to occur.

Acute pain is best treated through a multimodal approach that combines different pharmacological and nonpharmacological therapies. Opioid therapy is one treatment option within this approach, and one that is commonly used: In the first 3 months of 2016 in Ontario, 24% of people who filled a prescription for opioid analgesics received a one-time supply of short-acting medication for a duration of 14 days or less, suggesting the medication was prescribed for acute pain. However, opioids are often prescribed for acute pain conditions when non-opioid treatments would be similarly effective.

There are also troubling variations across Ontario in how opioids are prescribed for acute pain. For example, the percentage of new opioid prescriptions issued by surgeons in 2016 that exceeded the recommended 7-day supply varied more than twofold by local health integration network (LHIN) region, ranging from 7.4% to 16.7% (Narcotics Monitoring System, Ministry of Health and Long-Term Care, November 2017). There are also variations in the daily dose of opioids prescribed, with 21% to 42% of new opioid prescriptions from surgeons in Ontario exceeding the recommended dose of 50 mg morphine equivalents across LHIN regions (Narcotics Monitoring System, Ministry of Health and Long-Term Care, November 2017).

The potential benefits of opioid therapy for acute pain are short-term pain control and a quicker return to normal function. The potential harms include the risks of long-term use, addiction, overdose, and death. The presence of unused prescribed opioids in the community also poses a safety risk to others and has the potential for diversion.

Appropriate opioid prescribing practices—including dose reduction and discontinuation—combined with an understanding of patient preferences and values, can help reduce the risk of people with acute pain being subjected to opioid-related harms.

This quality standard is underpinned by the principles of respect, equity, and patient safety.

People with acute pain who have been prescribed or are considering opioid therapy should receive services that are respectful of their rights and dignity and that promote shared decision-making.

People with acute pain should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, linguistic, ethnic, and religious backgrounds), and disability. Equitable access to the health system also includes access to culturally safe care. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, in predominantly Anglophone settings, services should be actively offered in French and other languages.

Health care professionals should be aware of the historical context of the lives of Canada’s Indigenous peoples and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

A high-quality health system is one that provides appropriate access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

The Opioid Prescribing for Acute Pain Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that may be used to assess quality of care provincially and locally.

How Success Can Be Measured Provincially

  • Rate of opioid-related deaths

  • Urgent hospital use:

    • Rate of opioid-related emergency department visits

    • Rate of opioid-related hospital admissions

  • Prescribing:

    • Rate of people prescribed opioid therapy (proxy measure)

    • Rate of opioid prescriptions dispensed (proxy measure)

    • Number of opioid tablets and patches dispensed (proxy measure)

Proxy indicators are measures that approximate the intended indicator. In this case, the proxy indicators use data from a broader cohort (e.g., the population of Ontario) since data on the specific cohort of interest (i.e., people with acute pain) is unavailable.


How Success Can Be Measured Locally

You may want to assess the quality of care you provide to people with acute pain when considering prescribing opioids. You may also want to monitor your own quality improvement efforts. It may be possible to do this using your own clinical records, or you might need to collect additional data.

In addition, each quality statement within this quality standard is accompanied by one or more indicators. These indicators are intended to guide measurement of quality improvement efforts related to implementation of the statement.

It is exciting to see that theOpioid Prescribing for Acute Pain Quality Standard considers the person with acute pain to be an integral part of the healthcare team, as it is important to me that I can speak with my health care provider about the options for managing my pain. I am also glad to see that this quality standard provides information on evidence-based methods for managing acute pain beyond the use of opioids.

The patient reference guide will serve as an important communication tool for patients and their providers. My hope is that it will empower other people with lived experience and equip them with the information and tools to become actively involved in managing their pain.

- Judie Craig, Lived Experience Advisor Panel Member, Opioid Prescribing for Acute Pain Quality Standard Advisory Committee

Canadians are among the highest consumers of prescription opioids in the world, and the link between prescription opioid use and patient harms is clear. The goal of this standard is to balance concerns for patient pain and suffering with responsible opioid prescribing to minimize risk of these patient harms.

There is much to be learned about evaluating risk of harms related to opioid use. Determining the development of opioid use disorder is challenging and limited to identifying individuals with ongoing opioid prescriptions or presentations of pain. The likelihood that we are significantly underestimating patient harms associated with opioid prescribing, even in the acute care setting, is high.

This quality standard recognizes that there is some risk associated with any opioid prescription, but aims to improve patient safety and care in several meaningful ways. First, it makes specific recommendations regarding appropriate dose and duration of opioid therapy for acute pain. Second, it emphasizes the important need for patient and provider education about the potential benefits and harms of opioid use. Finally, this standard provides a framework for improved communication between patients and providers, leading to better care.

Opioid medications are important tools for relieving patient pain and suffering. All clinicians have an obligation to participate in appropriate opioid stewardship, and to minimize the harms associated with opioid use.

- Bjug Borgundvaag, Co-Chair, Opioid Prescribing for Acute Pain Quality Standard Advisory Committee

This quality standard was completed in March 2018.

For more information, contact QualityStandards@HQOntario.ca.

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