Prescribing Guidelines

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This document offers a unified approach to guide physicians in the appropriate initiation of opioids for acute non-malignant pain. Acute pain is defined as pain that is provoked by a specific disease or injury, or occurs subsequent to surgery, and is self-limited, lasting no longer than 90 days. The document offers guidance on pain assessment and reassessment, non-opioid alternatives, risk assessment, opioid prescribing, patient counseling and discharge planning.

This document offers support to providers in delivering care to patients suffering from chronic, non-malignant pain, while reducing the number of people inappropriately prescribed opioids and those continued on opioids who are not achieving functional goals, have serious side effects, or exhibit concerning behavior. These guidelines recognize that there are some patients who may benefit from chronic opioid therapy (i.e., prescribed for greater than 90 days) as a component of their management. These guidelines do NOT apply to patients with active cancer and malignancy associated pain or patients receiving hospice or palliative care. Before opioids are prescribed for chronic non-malignant pain, a diagnosis must be established, the patient must be screened for risk of misuse (including checking the Prescription Monitoring Program), and a plan of care documented.

The objective of this guideline is to address the potential difficulty in achieving analgesia for patients who present for elective and emergent surgery and are taking buprenorphine and to offer guidance to achieve appropriate perioperative pain management.

                                                 

This detailed, multidisciplinary document provides recommendations on pain assessment and management. Information on opioids includes pharmacology; equianalgesic dosing; guidance on use of methadone, fentanyl and PCAs; management of side effects; guidance for weaning; inpatient treatment of opioid-induced respiratory depression and available formulations. Other information presented includes dosing, recommended use and available formulations of all classes of adjuvant analgesic agents (e.g., NSAIDS, anti-convulsants, anti-depressants and muscle relaxants).

                                              

This document provides 2 tables useful for the ordering of IV PCAs. The first, is the ordering grid that aides in choosing the best template (i.e., High Risk, General, Opioid Tolerant, and Palliative Care) for the patient, based on their demographics and state of opioid tolerance. The second, lists each template and specific opioid, the order guardrails and the default patient bolus doses and lockout intervals, as well as the upper limit of the continuous infusion allowable.

Equianalgesic Opioid Dosing Table and Conversion Example

This document provides a table of approximate equianalgesic doses (i.e., doses, in an opioid-naïve patient, that will provide a similar analgesic effect) for the most commonly used opioids. It also goes through a step-by-step example of how to do a conversion from one opioid to another, taking into account incomplete cross-tolerance.

Online Opioid Conversion Program - single agent

This external program aides you in converting from one opioid to another (or one route to another) by performing the calculation for you after you enter the present daily opioid dose, the opioid you wish to convert to and the percent of incomplete cross tolerance you wish to use.

Online Opioid Conversion Program - multiple agents

This external program aides you in converting from a few different opioids to a single agent by performing the calculation for you after you enter the present daily opioid doses, the opioid you wish to convert to and the percent of incomplete cross tolerance you wish to use.