The post-acute pain prescribing interval is between four and 45 days following a severe injury, severe medical condition, or a major surgical procedure or trauma. This timeframe represents a critical period for secondary prevention of chronic opioid use and substance use disorder. Opioid use for acute pain is associated with long-term opioid use and a greater amount of early opioid exposure is associated with greater risk for long-term use (Alam, 2012; Deyo, 2016, Guy, 2017). In addition, because physical dependence on opioids is an expected physiologic response in patients exposed to opioids for more than a few days, it is imperative that a prescriber work with the patient to limit the days of opioids prescribed following an acute event.
Pain intensity and pain interference with normal function should decrease during the post-acute pain phase as part of the natural course of recovery following surgery or injuries. Patients may continue to experience acute pain induced by a severe injury or invasive procedure and treatment should continue accordingly. Patients who experience pain during this phase should receive aggressive, multi-modal pain treatment in order to improve function, manage pain and prevent future transition to chronic pain and chronic opioid use. Avoid continued use of opioids to treat post-acute pain and plan to taper patients off opioids by 45 days after the acute event.
Clinicians must be aware that patients may become opioid-dependent within this timeframe. Physiologic pain processes may begin to transition from acute to chronic mechanisms. Assessment of pain and function at each follow-up visit during this period is necessary to document changes over time. Early and ongoing risk assessment is necessary to identify psychosocial risk factors that may predict chronic use, the development of opioid use disorders and the transition from acute to chronic pain.
Continued assessment of pain interference and functional status in the post-acute period can be valuable for tracking improvement and gauging whether healing and recovery is progressing normally. Use functional assessments—in concordance with pain assessments—to guide patient-provider conversations about pain management and psychosocial factors that may contribute to the experience of pain.
Patients that report pain intensity or severity beyond the anticipated treatment duration, or functional limitations disproportionate to the nature of the injury or trauma, will require additional assessment. Clinicians should obtain contextual information from the patient regarding his or her experience and limitations with pain and assess whether psychosocial issues are potentially affecting the pain experience.
Refer to the Acute and Post-Acute Pain Prescribing and Assessment Recommendations Guide for recommended screenings and timing of the screenings in the post-acute pain interval, as well as Biopsychosocial Assessment and Risk Assessment for discussion and additional recommendations about assessments.
Opioid prescribing patterns in the post-acute pain interval present challenges to monitoring utilization and safety. The patient may obtain prescriptions from a number of different prescribers based on the nature of the acute event. Prescribers may be located in different medical groups, or separated by significant geographic distance. Prescriptions written with intended tapering may appear larger than the intended use. On the other hand, patients may not understand how to gradually discontinue their dosage. Checking the PMP every time a refill is requested in the post-acute pain interval provides the prescriber with a history of the patient’s past opioid and other medication use.
Experts agreed that a standard dosage and duration recommendation is helpful in this interval, despite the nuances related to dose reduction and discontinuation. The work group members also agreed that prescribers should understand the cumulative morphine equivalence exposure of the patient since the initial prescription for acute pain. Two recent studies suggest significant risk points related to cumulative morphine equivalence exposure. One study found that the largest increment in probability of continued use was observed at 700 MME cumulative dose. (Guy, 2017) The other study found that opioid naïve patients who received a cumulative dose of 400 – 799 (versus ≤ 120) MME in the first month of use were 2.3 and 3.0 times as likely to become chronic opioid users (Deyo, 2016).
Patients exposed to opioids for a short period are not likely to need a formal taper regimen. Patients exposed to opioids for greater than two weeks following an acute event may require a formal taper. Explain to the patient that mild withdrawal symptoms are expected and do not represent a need to adjust the taper. Discuss symptoms of withdrawal with the patient and instruct the patient to contact you if he or she experiences any of these symptoms. Withdrawal signs and symptoms may include gastrointestinal symptoms, anorexia, yawning, lacrimation, salivation, rhinorrhea, piloerection, insomnia, anxiety, irritability, dysphoria and manifestations of sympathetic hyperactivity such as diaphoresis, tachycardia, fever, mydriasis or mildly elevated blood pressure (Farrell, 1994).
Decisions regarding a tapering schedule should be made on an individual basis, in consideration of the patient’s symptoms and in conjunction with the patient and his or her caregivers, if appropriate. Patient education is essential to a successful taper. Provide clear written and verbal instructions to patients to educate them about the taper protocol, ways to minimize withdrawal symptoms and the proper way to dispose of opioids. Consider adjuvant medications—antidepressants, NSAIDS, clonidine, anti-nausea and anti-diarrhea agents, as indicated—for patients experiencing withdrawal symptoms.
Seek consultation or refer a patient to a pain medicine specialist when the taper regimen is complex, when the patients fails to taper successfully in an outpatient setting, or when pain continues after tissue healing progresses
