Future Changes in Acute Pain Prescribing
By Christopher T. Dietrich, MD
SDSMA President

The South Dakota State Medical Association (SDSMA) has been working in conjunction with the South Dakota Department of Health (SDDOH) to address the opioid epidemic in our state. While South Dakota has the fifth lowest age-adjusted rate of opioid-related deaths at five per 100,000, prescription drug abuse is a problem to which South Dakota is not immune. In 2017, we lost 35 of our family members and friends to an opiate-related drug overdose. An additional 33 were lost to illicit drug use. 

To date, the SDSMA in partnership with the SDDOH, have developed a white paper on chronic non-cancer pain, conducted numerous educational sessions – both live and via the internet, and a released a clinical toolbox for providers and patients which has been made available on the SDSMA website. These measures have resulted in significant decreases in both the number of pills prescribed and in the total MME (morphine milligram equivalent) prescribed. While significant progress has been made, we have room for improvement in the area of acute pain management.

A number of studies demonstrate increased risk of new persistent opioid use in opioid-naïve patients after having been prescribed opioids for acute pain. Problems can occur in as few as five days of use. The SDSMA’s Committee on Pain Management and Prescription Drug Abuse has reviewed current literature and existing clinical guidelines in order to articulate the following recommendations for effective and responsible treatment of acute pain, including the use of opioid analgesics. 

The basic strategy for treating acute pain can be summarized as:
1. Assess the degree of expected or actual pain from an injury, surgery, or procedure
2. Consider patient-related and drug-related factors
3. Use multimodal pain control methods, emphasizing, when appropriate, non-pharmacological methods and non-opioid pharmacotherapy
4. If opioids are deemed necessary prescribe only an amount to cover the expected pain or realistic duration of time to a follow-up appointment
a. Check PMP AWARxE, South Dakota’s prescription drug monitoring program
b. Screen for risk factors such as history of substance abuse disorder or mental illness
c. Prescribe only short-acting opioids
d. Discuss with patients safe storage, use, and disposal of opioids
e. Taper or discontinue opioids as soon as possible
f. Re-evaluate patients if healing or disease process does not follow expected course

Guidelines from the Centers for Disease Control and other organizations strongly recommend that only short-acting opioids be prescribed for acute pain because they reach peak effect more quickly than extended-release formulations and the risk of unintentional overdose is reduced. Only enough opioids should be prescribed to address the expected duration and severity of pain from an injury or procedure (or to cover pain relief until a follow-up appointment). Several guidelines about opioid prescribing for acute pain from emergency departments and other settings have recommended prescribing three or fewer days of opioids in most cases, whereas others have recommended seven or fewer days, or 14 or fewer days. CDC guidelines suggest that for most painful conditions (barring major surgery or trauma) a three-day supply should be enough, although many factors must be taken into account (for example, some patients in South Dakota might live so far away from a health care facility or pharmacy that somewhat larger supplies might be justified). 

In the coming months, the SDSMA Committee on Pain Management and Prescription Drug Abuse will release a second white paper to provide guidelines and recommendations to prescribers on the treatment and management of acute pain. Upon its’ release, we will encourage all prescribers to review the white paper. In doing so, we also encourage prescribers to incorporate the South Dakota Prescription Drug Monitoring Program (SD PDMP) into their practice. While the SDCL 34-20 requires prescribers of controlled substances to be registered with the SD PDMP, nothing mandates its use. Doctor shoppers move through our system utilizing acute, non-established visits – hopping from emergency departments to urgent care to an outpatient clinic. These patients can be identified through the SD PDMP and referred for treatment by incorporating SD PDMP data into practice.

As we make changes in our acute pain prescribing habits we expect to see even more improvements in the total number of pills prescribed. This in-turn should lead to less left-over pills in patients’ homes and in our communities. The prescribing of five or less days of medication should also decrease the number of patients who develop an addiction.
With everything, slow and steady wins the race, and success comes from discipline, perseverance and forward progress one step at a time. Therefore, in looking ahead and beyond that of prescribing practices, our future direction for improvement includes expansion of psych services, addiction evaluation and treatment programs, and long-term counseling and treatment programs.

Resources

1. Davis C. State-by-state summary of opioid prescribing regulations and guidelines. The Network for Public Health Law; 2017.
2. South Dakota Department of Health. Prescription opioid abuse prevention initiative. Retrieved from https://doh.sd.gov/news/Opioid.aspx
3. Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recommendations and Reports. 2016;65(1):16.
4. Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Internal Medicine. 2015;175(4):608-15.