Oregon Discourages Excessive Opioid Prescribing In Guidelines For Acute Pain

A state report on opioid prescribing guidelines for acute pain said prescriptions should be a last resort and limited in duration, to decrease chances of long-term use and addiction.

Oregon released guidelines Thursday that encourage providers to prescribe opioids for acute pain only when necessary and to limit the length of time that patients take the painkillers.

The guidelines are part of a years-long effort by the Oregon Health Authority to prevent opioid abuse and misuse. The state endorsed prescribing guidelines by the Centers for Disease Control and Prevention in 2016 that encouraged providers to consult colleagues when prescribing high doses, test for other drugs and monitor patients’ marijuana use.

These guidelines are the first in Oregon to focus on prescribing for acute pain, which the state health officer, Dr. Katrina Hedberg, noted is important because that’s often where opioid dependencies start. When patients with acute pain, from a sprain, surgery or a broken bone, for example, are prescribed opioids they often continue to take them for lingering chronic pain, Hedberg said.

Minnesota and Indiana also have opioid prescribing guidelines for acute pain.

“We know that folks who are on chronic opioids got their first prescription at some point,” Hedberg said. “The purpose of these guidelines is really to try to decrease the number of people who become dependent on opioids.”

The recommendations also attempt to reduce the number of unused opioids in circulation so that they don’t get into the hands of teens or others who may misuse them. Many patients do not take all the medications they’re prescribed, resulting in leftover pills, the report said.

That can pose a huge hazard for teenagers, said psychologist Catriona Buist, former chair of the Oregon Pain Management Commission. Citing an example, she said teens hold “skittling” parties where they grab a handful of leftover pills from their parents, throw them in a bowl and take them randomly.

“We’ve got this surplus sitting around in medicine cabinets and that’s even more dangerous,” Buist said,

The recommendations say that opioids should not be considered the first option for patients experiencing mild to moderate pain. It encourages providers instead to treat acute pain with over-the-counter medications or ice, for example.   

If those treatments are ineffective and opioids are appropriate, the rules say providers should prescribe the “lowest effective dose” of short-acting opioids for less than three days. In more severe cases, prescriptions should be limited to less than seven days, the guidelines say.

“The longer someone is on opioids for that acute event, the higher the likelihood that they will (become) dependent on opioids,” Hedberg said.

The report says not to prescribe opioids with benzodiazepines such as Xanax “unless there is compelling justification” for it. It also recommends specifying times for a patient to take the pills as opposed to ranges and explaining the risk of toxicity when combining medications.

Providers should assess the severity and likely duration of pain, the patient’s age and any other factors that might affect metabolism or the other medications the patient takes, the report says.

It instructs providers to look for a history of long-term opioid use or substance abuse disorder and to check the drug monitoring program that tracks prescriptions of controlled substances.

Finally, the guidelines encourage providers to educate patients about the expected duration of pain after a procedure, to inform them of the risk of addiction and to follow-up with patients before approving a refill. 

The guidelines apply to patients in outpatient care, dental care or post-surgery care. They do not apply to patients with chronic pain or those who have depended on the pain medications long-term. Nor do they address acute pain from medical conditions that sometimes require hospitalization such as a sickle cell pain crisis, pancreatitis, kidney stones or severe burns.

The report makes it clear that the recommendations do not address the treatment of very young children, the elderly or people with a substance abuse disorder.

“Opioids should only be prescribed when necessary for acute painful conditions due to the associated risks of long-term opioid use, misuse and overdose,” the report says.

The prescribing guidelines follow recommendations from the Centers for Disease Control and Prevention. A CDC analysis showed that the likelihood of chronic opioid use increases each additional day that the patient takes the medication, starting with the third day.

More than 30 percent of patients who received a 30-day prescription remained on opioids a year later, the study found.

Oregon used to have a liberal prescribing policy, stemming from concerns about patient comfort, but the opioid abuse epidemic that swept the county hit Oregon hard. In 2011,12 people per 100,000 were hospitalized due to opioids and more than 330 died. The number of prescriptions kept rising after that, hitting a high of more than 260 per 100,000 patients in 2015.

Oregon’s prescribing pendulum has since swung in the other direction following a number of state actions aimed at curtailing opioid prescribing. They include a requirement that providers taper Medicaid patients with back and spine conditions off opioids entirely.

A task force is now considering broadening that to Medicaid patients with chronic pain or fibromyalgia. Some chronic pain patients have protested, saying such a drastic rule would go too far.

Hedberg said the acute pain prescribing guidelines are not related to the chronic pain guidelines under consideration. However, the acute pain report directs health-care systems and clinics to “endorse the Oregon guidelines for opioid prescribing, including the guidelines for chronic and acute pain.”

In the meantime, the acute pain prescribing guidelines ask clinics and health-care groups to incorporate the new recommendations into their workflow process, to monitor the effects of the new rules and identify more detailed best practices for acute prescribing going forward.

The guidelines aren’t mandatory but are likely to be widely followed. 

“The guidelines are a really good start to try to prevent people getting stuck on opioids for long periods of time,” said Buist, former chair of the Oregon Pain Management Commission.

You can reach Jessica Floum at [email protected].