The Taste in Opioid Prescribing

Hey friends 👋🏻

As I was preparing for the second episode of the Opioid Conversion Book Club Series over the last two weeks, I came across a very interesting piece from Fast Fact called:

Opioid Orders: Good and Bad Examples

😬

That’s a pretty pointy title at first glance. Good and bad. So there’s going to be opinion involved. Judging something as good or bad has a lot to do with someone’s taste.

And someone’s caviar can be someone else’s durian.

So for this week, how about we look at some of the author’s critiques together and start developing our own taste in opioid prescribing?

Here's the case:

https://www.mypcnow.org/fast-fact/oral-opioid-orders-good-and-bad-examples/?print=print

Critique 1

“The duration of short-acting opioids is typically 3–4 hours, rarely 6 hours. Studies document that when given a range, nurses and clinicians are most likely to give the lowest dose at the longest interval, leading to inadequate analgesia.”

• I like parts of this critique, but I feel differently about other parts. I do agree that short-acting opioids work for about 3–4 hours. I sometimes try patients on every 6 hours so we can sprinkle in topicals and acetaminophen in between.

• I practice in a way that reserves opioids for more critical moments, acknowledging that some patients have more of those moments than others. I also let patients know that being generous with opioids early on may hasten tolerance. So they have to choose.

Critique 2

“Only one opioid/ non-opioid combination should be prescribed at a time. This is due to the potential for unsafe dosing of acetaminophen (or ibuprofen depending on the specific combination). Assess for response and change to a different product if the first agent does not produce the desired effect.”

• This is chef’s kiss. The logic is on point. This is especially true for older patients with limited health literacy. Providing two short-acting options and letting patients mix and match is setting them up for failure.

Critique 3

“The use of descriptors (‘mild,’ ‘moderate,’ ‘severe’) allows for subjective interpretation of pain severity by the nurse, rather than judging pain severity directly based on patient report. There is a poor correlation of pain ratings between patients and clinicians.”

• Hmm… this one is loaded. I’m not sure using a numeric scale is any better in practice, other than for standardization. Anyone who’s used numeric scales knows their limitations in capturing the depth of pain.

• Pain is subjective, and adding more subjectivity from nurses to an already subjective matter may seem confusing. But there is value in nursing input. I ask nurses all the time, “How do they look?

Critique 4

“Should both drugs be used, there is risk of exceeding 4 grams/day of acetaminophen.”

• Again, chef’s kiss. Combination products often contain acetaminophen that patients don’t realize they’re taking. Add in over the counter products that contain acetaminophen, and it’s easy to exceed the daily limit.

• Food for thought: what is your daily limit for acetaminophen? 3000 mg or 4000 mg?

And finally, the author suggested this as the preferred prescription:

Oxycodone with acetaminophen, 1–2 tabs PO every 4 hours PRN pain

Do you agree?

Thank you for reading, as always 🙇🏻

SP