Attempts to Limit Opioid Prescribing in Critically Ill Patients: Not So Easy, Not So Fast

Objective: To discuss why opioids have been considered the long-standing first-line therapy for treating acute, severe nociceptive pain in critically ill patients and discuss considerations for limiting opioid overuse in the intensive care unit setting. Data Sources: Articles were identified through searches of PubMed and EMBASE from database inception until December 2018. Additional references were located through a review of the bibliographies of articles and clinical practice guidelines. Study Selection and Data Extraction: Original research articles excluding case reports were included if they concerned nonopioid agents for pain management in critically ill patients. The focus was on studies not included in the most recent pain management guidelines. Data Synthesis: Ten studies were retrieved. Nonopioid therapies or opioid-sparing therapies have been touted as possible alternatives for critically ill patients, but they have particular adverse effects concerns in critically ill patients, often lack parenteral dosage forms, and frequently require dose adjustment or avoidance in patients with renal or hepatic dysfunction. Relevance to Patient Care and Clinical Practice: There is a well-recognized opioid epidemic that has been the subject of much discussion. Attempts to control the epidemic have focused on limiting opioid prescribing and using nonopioid alternatives, but there are special considerations when treating severe pain in critically ill patients that often preclude nonopioid analgesics. Conclusions: There continues to be an unmet need for medications that are as effective as opioids for severe nociceptive pain in critically ill patients but without the adverse effect and abuse concerns. Until such medications are available, clinicians need to optimize prescribing of opioid and nonopioid analgesics.