Acute Care Opioid Treatment and Prescribing Recommendations:

A Summary of Best Practices

These recommendations are to be used as a clinical tool, but they do not replace clinician judgment.

Surgical Department

Preoperative Counseling: For patients not using opioids before surgery

  • Discuss the expectations regarding recovery and pain management goals with the patient.
  • Educate the patient regarding safe opioid use, storage, and disposal.
  • Determine the patient’s current medications (e.g., sleep aids, benzodiazepines), and any high-risk behaviors or diagnosis (e.g., substance use disorder, depression, or anxiety).
  • Do NOT provide opioid prescription, for postoperative use, prior to surgery date.

Intraoperative

  • Consider nerve block, local anesthetic catheter or an epidural when appropriate.
  • Consider non-opioid medications when appropriate (e.g., ketorolac).

Postoperative

  • Meperidine (Demerol) should NOT be used for outpatient surgeries.
  • If opioids are deemed appropriate therapy, oral is preferred over IV route.
  • Ensure all nursing, ancillary staff and written discharge instructions communicate consistent messaging regarding functional pain management goals.

For patients discharged from surgical department with an opioid prescription

  • The prescription drug monitoring program (PDMP) must be accessed prior to prescribing controlled substances schedules 2-5, in compliance with Michigan law.
  • Non-opioid therapies should be encouraged as a primary treatment for pain management (e.g., acetaminophen, ibuprofen).
  • Non-pharmacologic therapies should be encouraged (e.g., ice, elevation, physical therapy).
  • Do NOT prescribe opioids with other sedative medications (e.g., benzodiazepines).
  • Short-acting opioids should be prescribed for no more than 3-5 day courses (e.g., hydrocodone, oxycodone).
  • Fentanyl or Long-acting opioids such as methadone, OxyContin and should NOT be prescribed to opioid naïve patients.
  • Consider offering a naloxone co-prescription to patients who may be at increased risk for overdose, including those with a history of overdose, a substance use disorder, those already prescribed benzodiazepines, and patients who are receiving higher doses of opioids (e.g., >50 MME/Day).
  • Educate patient and parent/guardian (for minors) regarding safe use of opioids, potential side effects, overdose risks, and developing dependence or addiction.
  • Educate patient on tapering of opioids as surgical pain resolves.
  • Refer to opioidprescribing.info for free prescribing recommendations for many types of surgeries.

Dental

Pre-Procedure

  • Opioid prescriptions should not be written prior to completing a dental procedure.
  • Communicate a conservative philosophy by emphasizing the efficacy and appropriateness of over the counter medications’ analgesic properties.
  • Address dental pain through clinical intervention rather than opioid pain relief.
  • Refer patients to a free or low-cost dental program in the absence of insurance or financial constraints.

Prescribing

  • The prescription drug monitoring program (PDMP) must be accessed prior to prescribing controlled substances schedules 2-5, in compliance with Michigan law.
  • Conduct full dental and medical history of the patient and include analysis of current medications.
  • Identify any high-risk behaviors or diagnoses (previous substance use disorders, alcohol or tobacco use, psychiatric comorbidities including depression or anxiety).
  • Non-opioid therapies (e.g., acetaminophen, ibuprofen) should be encouraged as the primary treatment.
  • Non-pharmacologic therapies (e.g., acupuncture, mindful practice) should be encouraged when the patient is open to these alternative solutions to pain control.
  • For breakthrough or severe pain, short-acting opioids (e.g., hydrocodone, oxycodone) should be prescribed at the lowest effective dose for no more than 3-5 day courses.
  • Do not co-prescribe opioids with other sedatives or CNS depressant medications (e.g., benzodiazepines).
  • Consider offering a naloxone co-prescription to patients who may be at increased risk for overdose, including those with a history of overdose, a substance use disorder, those already prescribed benzodiazepines, and patients who are receiving higher doses of opioids (e.g., >50 MME/Day).

For patients discharged with an opioid prescription

  • Discuss the expectations regarding recovery and pain management goals with the patient.
  • Educate patient and parent/guardian (for minors) regarding safe use of opioids, potential side effects, overdose risks, and developing dependence or addiction as required by Michigan law.
  • Emphasize not using opioids concomitantly with alcohol or other sedative medications (e.g., benzodiazepines).
  • Educate patient on tapering of opioids as dental/oral pain resolves.
  • Refer to Michigan-Open.org for additional patient resources.

Emergency Department (ED)

For patients presenting with acute exacerbation of chronic non-cancer pain

  • Non-opioid therapies should be used as first line therapy.
  • Lost or stolen prescriptions should not be replaced.
  • The prescription drug monitoring program (PDMP) must be accessed prior to prescribing controlled substances schedules 2-5, in compliance with Michigan law.
  • Consider care coordination and/or effective ED-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) with patients that have suspected risky opioid use or frequent ED visits.

For patients in methadone maintenance programs

  • Replacement methadone should NOT be provided in the Emergency Department (ED).

For patients presenting with acute painful conditions

  • Non-opioid therapies (e.g., acetaminophen, ketorolac) are encouraged as primary or adjunctive treatments.
  • Non-pharmacologic therapies (e.g., ice, splinting) should be utilized.
  • The prescription drug monitoring program (PDMP) must be accessed prior to prescribing opioids, in compliance with Michigan law.
  • Meperidine (Demerol) should not be used.

For patients discharged from the ED with an opioid prescription for acute pain

  • Long-acting opioids (e.g., fentanyl, methadone, OxyContin) should NOT be prescribed.
  • Short-acting opioids (e.g., hydrocodone, oxycodone) should be prescribed for no more than three-day courses.
  • Do not prescribe opioids with benzodiazepines and other sedatives.
  • Information should be provided about opioid side effects, overdose risks, potential for developing dependence or addiction, avoiding sharing and non-medical use, and safe storage and disposal.
  • Consider offering a naloxone co-prescriptions to patients who may be at an increased risk for overdose, including those with a history or overdose, a substance use disorder, those already prescribed benzodiazepines, and patients who are receiving a higher doses of opioids (e.g., >50 MME/day).
Prescription Drug & Opioid Abuse Commission
Michigan Opioid Prescribing Engagement Network
MI Injury Prevention Center