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Stepwise Approach for the Prescription of Opiates for Non-Cancer Pain: A Review of Clinical Evidence and Guidelines

Published on: May 12, 2014
Project Number: RC0548-000
Product Line: Rapid Response
Research Type: Drug
Report Type: Summary with Critical Appraisal
Result type: Report

Report in Brief

Context
In Canada, the prescribing of opioids for pain management increased by about 50% between 2000 and 2004. This increase has been accompanied by a rise in the rates of overdose, addiction, and misuse.

Technology
Opioids include codeine, tramadol, buprenorphine, morphine, hydromorphone, oxycodone, fentanyl, and methadone. Although opioids are effective for managing pain, they also carry a risk of overdose and other harms. Therefore, a stepwise approach — starting with lower-potency medications and gradually increasing the potency as pain management becomes less effective — is recommended.

Issue
A review of the clinical evidence and guidance regarding the use of a stepwise approach to the prescription of opiate analgesics for pain management in the emergency department or in-hospital setting will help to inform decisions about pain control in these environments.

Methods
A limited literature search was conducted of key resources, and titles and abstracts of the retrieved publications were reviewed. Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Results
The literature search identified 286 citations, with 6 additional studies identified from the grey literature. Of these, 12 articles were deemed potentially relevant, with 2 meeting the criteria for inclusion in this review: 1 systematic review of guidelines on opioid prescribing for chronic pain and 1 guideline on prescribing opioids in the emergency department.

Key Messages

  • Regarding the use of a stepwise approach to the prescription of opioid analgesics for pain management in the emergency department or in-hospital setting:
    • No clinical evidence was found.
    • No guidelines were found.
  • Guidelines for the management of chronic pain or pain in the emergency department recommend prescribing low doses of opioids for a limited duration, increasing the doses slowly, and using upper-dose thresholds (based on lower-quality evidence or expert opinion).

Question

  1. What is the clinical evidence regarding the use of a stepwise approach to the prescription of opiate analgesics for pain management in the emergency department or in-hospital setting?
  2. What are the evidence-based guidelines regarding the use of a stepwise approach to the prescription of opiate analgesics for pain management in the emergency department or in-hospital setting?

Key Message

No clinical evidence could be identified regarding the use of a stepwise approach (from lower to lower to higher potency) to the prescription of opioid analgesics for pain management in the emergency department or in-hospital setting. Guidelines for chronic pain or for pain management in the adult emergency department recommend the use of low dose and titrate cautiously, if opioids are indicated.

Tags

prescriptions, pain, opioids, analgesics, chronic pain, inappropriate prescribing, analgesics, opioid, other miscellaneous topics, step wise, Prescribing, Prescribe, Opioid, ladder