Opioids and acute pain management
*NNT (number needed to treat). The number of patients needed to be treated for one to benefit compared with a control. A treatment that works for everyone, and where no patient has a response with control, would have a NNT of 1. The higher the NNT, the less effective the treatment.
Opioids and acute pain management
The treatment of acute pain is essential to facilitate recovery from surgery or trauma by enabling early mobilisation and avoiding complications, including the bed-bound risks of venous thromboembolism, pulmonary embolus, pressure sores and pneumonia. Severe untreated acute pain may also predispose to the development of chronic pain.
Opioids are very effective in treating acute pain and are best used as part of a multimodal analgesic approach in combination with paracetamol, non-steroidal anti-inflammatory drugs and local anaesthetics where appropriate. Initiating opioids in the acute setting requires a prescriber to ensure that the opioids are not continued beyond the expected period of tissue healing.
A Canadian study showed that, although the inflammatory response to injury normally resolves within three months, a significant proportion of patients given opioids for post-operative pain took opioids well beyond this time. Pressures for earlier discharge from acute hospitals result in the potential for patients leaving hospital after a short stay with a supply of strong opioids. Although it is essential to supply patients with appropriate analgesia on discharge, clear information for the patient regarding the importance of tapering and stopping these drugs, and good communication with the patient’s primary care team should reduce the unnecessary continuation of opioids in the community.
There are a small number of patients who repeatedly present to an acute hospital describing pain and requesting opioid analgesia. They are often difficult to assess and manage. Developing an individualised management plan for these complex patients is essential. This will reduce unnecessary tests and provide a clear analgesic strategy. A multidisciplinary approach involving social, primary and secondary care is most likely to produce a robust and appropriate outcome. The Royal College of Emergency Medicine has produced best practice guidelines regarding the identification and management of frequent attenders in the Emergency Department.
Oxford Analgesic League Table
Single dose analgesics for moderate to severe acute pain: NNT* for at least 50% maximum pain relief over four to six hours.
* NNT (number needed to treat). The number of patients needed to be treated for one to benefit compared with a control. A treatment that works for everyone, and where no patient has a response with control would have a NNT of 1. The higher the NNT, the less effective the treatment. Treatments with NNTs of 2-5 are considered effective for acute pain.
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- Royal College of Emergency Medicine. Care of frequent attenders at multiple Emergency Departments. 2014.
- Thorson D, Biewen P, Bonte B, et al. Institute for Clinical Systems Improvement. Acute Pain Assessment and Opioid Prescribing Protocol. 2014.
- Wu CL, Cohen SR, Richman JM et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005;103:1079–88.