Help Treat Acute Pain in Patients on Chronic Opioids

You’ll get questions about treating ACUTE pain in patients who take opioids for CHRONIC pain.

These patients often need larger opioid doses...which can exceed the comfort zone of many clinicians.

Determine the patient’s daily opioid dose. Ask what they actually take, including avoid under- or overdosing.

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And confirm with state prescription drug monitoring programs.

Explain that a goal of zero pain isn’t realistic.

Instead, help focus on functional goals...such as relieving pain enough to participate in physical therapy or walk short distances. And distinguish between acute and chronic pain when assessing relief.

Recommend continuing the patient’s scheduled opioid regimen. Then suggest adding non-opioid therapies for acute pain...scheduled NSAIDs plus acetaminophen, lidocaine patches, ice packs or heating pads prn, etc.

Emphasize that non-opioids are at least as effective as opioids for many pain types (kidney stones, minor surgeries, etc).

If non-opioids aren’t enough, suggest adding a short-acting opioid (morphine, etc)...rather than increasing the long-acting opioid.

Short-acting opioids work faster...and are easier to adjust. Plus minimizing changes in the chronic regimen may prevent mix-ups later.

Start with a short-acting opioid dose that is about 10% to 20% of the current daily opioid regimen. Use a conversion chart to help.

For example, if a patient is using a 100 mcg/hr fentanyl patch, this is equivalent to about 240 mg/day of oral morphine. So 10% to 20% of the daily regimen works out to about 15 to 45 mg of morphine.

In this case, consider ADDING oral morphine 30 mg every 4 hours prn to the fentanyl regimen. Adjust the dose by about 50% until pain goals are met.

Use the shortest duration possible. For example, plan to de-escalate opioids within 3 days or less for minor surgeries.

Keep in mind, opioids used around the clock for more than a few days need to be tapered.

Follow a similar approach to manage acute pain for patients taking meds for opioid use disorder. Get our resource, Treatment of Acute Pain in Opioid Use Disorder, for specifics.

Key References

  • Dickerson DM, Mariano ER, Szokol JW, et al. Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Reg Anesth Pain Med. 2023 Apr 25:rapm-2023-104435. doi: 10.1136/rapm-2023-104435.
  • Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel). 2022 Dec 22;11(1):34.
  • Brulotte V. Acute pain management for chronic pain patients: expanding the role of the anesthesiologist. Can J Anaesth. 2023 Oct 19. doi: 10.1007/s12630-023-02610-3.
  • Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs. 2020 Jan;80(1):9-21.
  • Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022 Nov 4;71(3):1-95.
Pharmacist's Letter. April 2024, No. 400403

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