Protecting the patient: the dilemma of the first opioid prescription

Do we have to choose between the duty to relieve patients' severe pain as best we can, and the duty to protect them from the potential harm associated with first-time opioid use? Patients who have never used opioids before pose a particular challenge for clinicians as they may “seem to clinicians to be at low risk of harms from a new short-term opioid prescription, yet they may be at highest incremental risk,” wrote the team of Dr. Donna Reynolds, assistant professor in the department of family and community medicine and the Dalla Lana School of Public Health at the University of Toronto, in an article published in CMAJ. She is also a volunteer member of the Canadian Task Force on Preventive Health Care (CTFPHC).Higher rates of prolonged useResearchers at the University of Alberta performed a related population-based observational cohort study, using administrative data to sample all Alberta emergency department visits over a 10-year period, excluding cancer patients, palliative care patients or patients using opioids concurrently.Of a total of 13,028,575 eligible visits, 689,074 treated patients (5.3%) filled an opioid prescription within 72 hours of their initial ED visit, noted the study also published in CMAJ. The authors found that opioid-treated patients in the ER had higher rates of prolonged opioid use (4.5% vs. 3.3%; number needed to harm [NNN] = 59) and all-cause hospitalization (16.4% vs. 15.1%; NNN = 53) than matched controls who did not receive an opioid prescription. Rates of opioid-related emergency room visits, new opioid agonist treatments and mortality were unaffected. Opioid-naive patients had the highest incremental risk of harm after opioid treatment (NNH = 21), despite lower rates of adverse events.No guidelines on the agendaHowever, there are as yet no guidelines to prevent clinician-initiated opioid use disorders, misuse and associated adverse effects in opioid-naive individuals. The GECSSP and the U.S. Preventive Services Task Force (USPSTF) have attempted to fill this gap by evaluating the possibility of developing guidelines on the subject. But the two organizations have come up against several obstacles, said the Toronto team in its CMAJ article. In addition to the lack of evidence on the pros and cons, and the absence of validated screening or other prevention tools for people who have never used opioids, they also point to two major obstacles to the development of such guidelines:The lack of a clear and accepted definition of “opioid naive.” Is it a patient who has never been prescribed or used opioids ever? Or in the last 6 to 12 months? Or is not currently taking them? Should patients be considered opioid-naive until their first refill after a short-term prescription?The lack of a standard definition of “short-term treatment” of opioids, and prescription durations that can differ depending on the causes of pain. According to observations by researchers at the University of Alberta, the most common diagnoses leading to opioid prescriptions in emergency departments were high intensity.“Ideally, for the initial prescription or renewal of short-term treatment in an opioid-naive patient, advice on screening for potential risk factors for progression to opioid harm or, failing that, interventions that patients and providers can use to reduce the likelihood of opioid harm, would be helpful,” the team wrote.Today, the GECSSP has abandoned guidelines on prevention of opioid misuse and short-term opioid-related harm in people who have never used opioids, as has the USPSTF, both due to above-mentioned obstacles.

Protecting the patient: the dilemma of the first opioid prescription

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