Implications of the opioid epidemic for critical care practice

The purpose of this paper is to consider the implications of the opioid epidemic for the critical care practitioner and provide recommendations to try to reduce the likelihood of opioid over-prescribing. The medical literature pertaining to the current opioid epidemic has focused on opioid overdose and deaths associated with the chronic use of opioids, but the issue has implications for the critical care pharmacist because excessive prescribing during hospitalization and at discharge may lead to chronic use. Guidelines are available concerning pain assessment and control in the critical care setting, but the evidence base supporting these recommendations is limited and often based on extrapolations from postoperative pain studies. While current pain management guidelines pertaining to critically ill patients place more emphasis and recommendations on nonopioid agents as adjuncts to opioids for severe pain, the recommendations for these adjuncts are tempered by a lack of higher-level evidence supporting their use and concerns related to adverse effects. Efforts to control opioid over-prescribing begin in the intensive care unit (ICU) with implementation of recommendations from current clinical practice guidelines that recommend appropriate assessments. After the ICU stay, attention should be focused on prescribing practices associated with patients' transition of care from hospital to home or other care facility, because this is where acute-to-chronic use is most likely to occur. Clinical pharmacist involvement in follow-up clinics postdischarge has the potential to improve patients' pain control by optimizing medication use.