Pain Management
Recommendation 1 suggests that nonopioid therapies should be the first line of treatment for many common types of acute pain. Nonpharmacologic approaches such as physical therapy, heat therapy, massage, and acupuncture, as well as nonopioid medications like NSAIDs and acetaminophen, are considered to be at least as effective as opioids for conditions such as low back pain, neck pain, musculoskeletal injuries, dental pain, kidney stone pain, and headaches including migraines.
The recommendation advises clinicians to maximize the use of nonopioid therapies appropriate for each specific condition and patient, and only consider opioid therapy if the benefits are expected to outweigh the risks. Before prescribing opioids, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.
Implementation considerations include the use of noninvasive nonpharmacologic approaches like heat therapy, massage, acupuncture, and spinal manipulation for acute pain management. It highlights the importance of improving access to these therapies, as they may not be fully covered by insurance and may present barriers for certain individuals. Additionally, nonopioid medications such as NSAIDs and acetaminophen are recommended for various acute pain conditions, while opioids should be reserved for severe traumatic injuries, invasive surgeries, and other cases where nonopioid therapies are contraindicated or ineffective.
When opioids are deemed necessary, clinicians should prescribe immediate-release opioids at the lowest effective dose and for the shortest duration necessary to manage the severe pain. The recommendation emphasizes prescribing opioids as needed rather than on a scheduled basis and encourages an opioid taper if opioids are taken continuously for more than a few days. Furthermore, if patients already receiving long-term opioids require additional medication for acute pain, nonopioid medications should be used whenever possible, and additional opioids should be continued only for the duration of the severe pain.
Clinicians should ensure that patients are fully informed about the expected benefits, common risks, serious risks, and alternative options to opioids before initiating or continuing opioid therapy. The recommendation emphasizes the importance of involving patients in meaningful decision-making regarding the use of opioids.
The supporting rationale emphasizes the critical role of patient evaluation in appropriate pain management, including identifying reversible causes of pain and underlying conditions that require urgent action. It highlights the evidence supporting noninvasive nonpharmacologic approaches, such as heat therapy, massage, and acupuncture, for acute pain relief. The recommendation also provides specific guidance on the use of nonopioid medications, including NSAIDs and acetaminophen, for different acute pain conditions. It further discusses the limitations and potential harms associated with opioid therapy, reinforcing the need for cautious and selective prescribing practices.
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