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.
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.
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.
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).
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.
- 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).