By Jill Drachenberg, Editor, Relias Media

When fighting the opioid epidemic, physicians can lead the way to reduce the number of opioid prescriptions. But when developing clinical practice guidelines (CPGs) around prescribing, many physicians may realize there is no easy answer. Some policies may be ethically problematic, imposing seemingly arbitrary limits on prescribing, as reported by Medical Ethics Advisor

The authors of a new report from the National Academies of Sciences, Engineering, and Medicine gives guidance and clarity to physicians in developing consistent CPGs for patients experiencing acute and chronic pain. While the report does not offer prescribing recommendations, it presents an analytical framework and an evidence evaluation framework to guide a clinician’s decision-making for prescribing opioids for procedures such as cesarean delivery, total knee replacement, extraction of wisdom teeth, and conditions such as migraines, low back pain, and kidney stones.

The analytical framework presents evidence-based factors and gaps clinicians should consider when a patient presents with acute pain:

• Whether the patient is opioid-naïve or opioid-exposed;
• Intermediate outcomes of the prescription, such as leftover pills, potential for drug misuse by the patient or family member, and potential for refill requests;
• Health outcomes in the patient population for long- and short-term opioid use, such as pain levels, quality of life, adverse effects, and morbidity and mortality.

The report authors detailed gaps in opioid prescribing practice that require further research:

• The effectiveness of opioids vs. nonopioid alternatives in treating pain;
• How opioid prescribing practices affect different patient populations;
• The effects of the clinical setting — such as EDs, primary care offices, and ambulatory surgery centers — on prescribing;
• The effects of pill quantities and leftover medication on health outcomes.

“Clinicians who prescribe opioids have to balance two distinct goals: relieving a patient’s severe pain, while minimizing the potential public health harms of opioid misuse and the resulting emotional distress to families and communities,” said Bernard Lo, president of the Greenwall Foundation and chair of the committee that wrote the report. “We hope the frameworks we suggest in the report will lead to more evidence-based prescribing guidelines that can help clinicians provide high-quality care to patients experiencing acute pain.”

Recently, the Institute for Healthcare Improvement (IHI) collaborated with Boston Medical Center to develop best practices for identifying and treating patients who present to hospitals with opioid use disorder. Initiating treatment in the ED can improve patient engagement and prevent or reduce the chance of opioid overdose, the IHI report co-author told Hospital Peer Review.