3 Opioid Analgesics and Safe Use

Opioids and appropriate use

Opioid analgesics act on opioid receptors in the nervous system to reduce pain perception. Examples include morphine, hydromorphone, oxycodone, hydrocodone, fentanyl, and methadone. Buprenorphine has partial opioid-agonist activity and is used in selected pain and opioid use disorder treatment plans.

Opioids may be appropriate for severe acute pain, some postoperative or traumatic pain, and selected cancer-related or palliative pain. For many common acute pain conditions, nonopioid treatments can provide comparable relief, so consider them first or use them alongside an opioid when appropriate.

Assess pain and combine treatments

Assess the person, not just a pain score. Ask about the pain’s location, onset, character, intensity, pattern, aggravating or relieving factors, and effects on sleep and daily activities. A self-report scale can help track intensity, but it does not show on its own whether function improved or adverse effects occurred.

Establish a meaningful functional goal, such as walking to the bathroom or sleeping for a longer stretch. After treatment, reassess pain, function, and adverse effects, using the same approach when possible. Evaluate whether treatment meets the patient’s goals.

Multimodal pain management combines treatments with different mechanisms to improve comfort and function while limiting reliance on any one medicine. Depending on the diagnosis and patient, a plan may include:

• Nonopioid analgesics: acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), when appropriate and not contraindicated.

• Adjuvant medicines: selected antidepressants or anticonvulsants for neuropathic pain; other adjuvants may be considered for particular conditions.

• Nonpharmacologic care: physical or occupational therapy, movement, heat or cold, rest, elevation, behavioral strategies, or other condition-specific approaches.

Select treatments according to the likely pain mechanism, medical history, other medicines, and patient preferences. When using combination products, check total acetaminophen exposure and account for relevant risks and contraindications with all medicines.

Individualize opioid dosing

Individualize opioid prescribing and administration to the patient and the specific medicine. Follow product labeling and the prescriber’s order; do not infer an individual dose from general guidance.

• Use the lowest effective dose. Consider opioid tolerance, age, frailty, kidney or liver impairment, sleep-disordered breathing, other illnesses, and concurrent medicines.

• Choose the formulation for the situation. For a new opioid start, use an immediate-release rather than an extended-release or long-acting opioid. Extended-release products are not for occasional or as-needed pain, and some are restricted to patients meeting the opioid-tolerance requirements in the product labeling.

• Limit acute-pain prescriptions. Prescribe no more than is needed for the expected period of pain severe enough to require an opioid. Use as-needed instructions when appropriate, and reassess if pain persists rather than allowing an acute prescription to continue automatically.

• Reassess before increasing a dose. Opioid risks increase with dose, and no single dosage threshold eliminates risk. Before increasing a total daily dose to $50$ morphine milligram equivalents (MME) or more, pause to reassess individual benefits and risks. MME helps compare opioid dosage across medicines when assessing overall exposure and risk; it is not a direct opioid-conversion dose.

• Avoid abrupt changes to long-term therapy. If reducing long-term opioids is appropriate, collaborate on an individualized taper. Except when an imminent life-threatening concern requires urgent action, do not abruptly discontinue or rapidly reduce long-term therapy.

Monitor effects and treatment risks

Before and during therapy, review medical conditions, the medication list, treatment goals, and risks. Monitor for pain relief and improved function as well as harm. Common adverse effects include constipation, nausea, itching, drowsiness, dizziness, and urinary retention. Constipation may persist during treatment; anticipate and manage it according to the patient’s needs and clinical plan. More serious effects include marked sedation and slowed or difficult breathing.

For subacute or chronic pain, reassess benefits and risks within one to four weeks after starting opioids or increasing a dose, with closer follow-up in higher-risk circumstances. During ongoing therapy, review whether pain and function are meaningfully improved, ask about adverse effects, and check for warning signs of overdose or opioid use disorder. Review the prescription drug monitoring program (PDMP) as recommended. Consider toxicology testing when results could help improve care, and discuss testing in a nonpunitive manner.

Tolerance, physical dependence, and opioid use disorder are different concepts. Tolerance means a person may need a different dose to produce the same effect. Physical dependence means withdrawal symptoms can occur if a regularly used opioid is stopped suddenly. Neither, by itself, establishes opioid use disorder, which involves a problematic pattern of use assessed clinically.

Recognize and respond to overdose

Overdose risk rises with excessive dosing, accidental ingestion, loss of tolerance, and combining opioids with other central nervous system depressants. Benzodiazepines, alcohol, sleep medicines, muscle relaxants, and some other sedating medicines can intensify sedation and respiratory depression; use particular caution with these combinations.

Possible overdose signs include inability to awaken, very slow or absent breathing, limpness, and blue or gray lips or fingertips. If overdose is suspected, call 911, give naloxone if available, and support breathing according to training and emergency-dispatch instructions. Give another naloxone dose if the person does not respond or symptoms return, following the product directions. Stay with the person until emergency help arrives. Naloxone can wear off before the opioid does. It can precipitate withdrawal in someone who is physically dependent, but suspected overdose requires urgent treatment.

Offer or discuss naloxone when overdose risk is elevated, including a history of overdose or substance use disorder, concurrent benzodiazepine use, sleep-disordered breathing, or higher opioid dosage. Teach the patient and household members how and when to use it.

Administer and store opioids safely

Before administration, confirm the medication, formulation, dose, route, timing, and patient identity against the order and local policy. Clarify ambiguous or unsafe orders. Assess pain and alertness before giving a dose; afterward, reassess therapeutic response and sedation or breathing as appropriate to the route, setting, and policy. Report concerning findings promptly and follow facility-specific monitoring and escalation procedures.

Do not crush, split, or chew extended-release products unless product labeling explicitly allows it. Never use another person’s medication or take doses more often than prescribed. Review other medicines and substances, including over-the-counter products, alcohol, and sedatives, and check for duplicate ingredients in combination products.

Store opioids securely away from children, visitors, and pets. Dispose of unused medication promptly through an authorized take-back program or another locally recommended method. Discuss benefits, risks, safe use, storage, naloxone when appropriate, and follow-up in clear, nonjudgmental language. Avoid punitive responses to concerning findings; use them to reassess safety and care needs.