Utilization Review Checklist
Opioids for Acute and Postoperative Pain
Derived from the ACOEM Opioids Guideline, edition 12 December 2023, as adopted into the California MTUS 27 March 2024. ICD-10 G89.11, G89.18, Z98.890, R52.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Contraindications and Cautions
Required
Whether the patient performs safety-critical work has been established; if so, at least 3.3 half-lives must pass to clear 90% of the opioid before those duties resume
“it is recommended that at least 3.3 half-lives (to clear 90% of the opioid) take place after” — p. 21
Procedures — the guideline treats each separately
Short-acting opioids for postoperative pain
Moderately Recommended.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence high
Indications
Any one of the following
Short-acting opioids for postoperative pain
“For postoperative pain management, a brief prescription of short-acting opioids as an adjunct to more efficacious treatments.” — p. 51
Required:
Postoperative pain, managed with a brief prescription of short-acting opioids as an adjunct to more efficacious treatments
“For postoperative pain management, a brief prescription of short-acting opioids as an adjunct to more efficacious treatments.” — p. 51
Contraindications and Cautions
All of the following
No illicit substance use — or objective evidence of significant trauma or at least moderate-severe injury
“Patients should not receive opioids if they use illicit substances, unless there is objective evidence of significant trauma or at least moderate-severe injuries.” — p. 52
AND
Caution where other sedating medications or substances are in use, and the guideline's caution list has been considered
“Due to greater than 10-fold elevated risks of adverse effects and death, considerable caution is warranted among those using other sedating medications and substances, including benzodiazepines, anti-histamines (H1-blockers), and/or illicit substances.” — p. 52
AND
The prescription drug monitoring database has been checked for other opioid prescriptions
“Prescription databases (usually referred to as PDMP) should be checked for other opioid prescriptions.” — p. 52
Prior Treatment
All of the following
Non-opioid prescriptions are the primary treatment and accompany the opioid
“Non-opioid prescriptions (e.g., NSAIDs, acetaminophen) should nearly always be the primary treatment and accompany an opioid prescription” — p. 51
AND
More efficacious treatments including therapeutic exercise, such as progressive early ambulation, especially after moderate to extensive procedures
“More efficacious treatments also include therapeutic exercises, such as progressive early ambulation, especially for moderate to extensive procedures” — p. 51
AND
Screening completed before initiating opioids for postoperative pain
“Screening is recommended for surgical patients prior to the initiation of opioids for postoperative pain (up to 4 weeks).” — p. 57
AND
Planning for postoperative opioid use began at the preoperative assessment, with a minimal effective dose strategy
“Planning for opioid use to treat postoperative pain should begin during the preoperative assessment, emphasizing a minimal effective dose strategy.” — p. 52
Dose, Duration and Discontinuation
Any one of the following
For postoperative pain the guideline makes no recommendation on a maximum daily dose
“There is no quality evidence for dose limits for postoperative patients using opioids, and thus there is no recommendation.” — p. 59
OR
A brief prescription — only a short course of a few days, and opioids generally not needed at all for minor procedures
“Opioids are generally not needed for minor surgical procedures; for the exceptions, only a short course of a few days is indicated.” — p. 51
Supported as a BRIEF prescription of short-acting opioids, and explicitly as an ADJUNCT — the guideline says non-opioid prescriptions should nearly always be the primary treatment and accompany the opioid. It names therapeutic exercise, including progressive early ambulation, as a more efficacious treatment, particularly after arthroplasty and fusion. Opioids are generally not needed for minor procedures at all.
Opioids for acute, severe pain
Recommended.
Strength of Evidence — Recommended, Evidence (C) · confidence high
Indications
Any one of the following
Opioids for acute, severe pain
“Severe injury with a clear rationale for use (objective functional limitations due to pain resulting from the medical problem, e.g., extensive trauma such as forearm crush injury, large burns, severe radiculopathy).” — p. 29
Required:
Acute severe injury with a clear rationale — objective functional limitations due to pain
“Severe injury with a clear rationale for use (objective functional limitations due to pain resulting from the medical problem, e.g., extensive trauma such as forearm crush injury, large burns, severe radiculopathy).” — p. 29
Dose, Duration and Discontinuation
Any one of the following
For opioid-naïve patients with acute pain, a maximum daily oral dose of 50 mg MME — at least 50
“For opioid-naïve patients with acute pain, the recommended maximum daily oral dose based on the risk of overdose/death is 50 mg MME” — p. 36
Supported where there is a severe injury with a clear rationale — objective functional limitations from pain, the guideline's examples being extensive trauma such as a forearm crush injury, large burns or severe radiculopathy. Back and neck pain NOT due to major trauma is excluded by name.
Routine opioids for nonsevere acute pain
Strongly Not Recommended. Routine opioid use is strongly not recommended for the treatment of nonsevere acute pain (e.g., low back pain, sprains, or minor/moderate injuries without signs of major tissue damage).
Strength of Evidence — Strongly Not Recommended, Evidence (A) · confidence high · p. 25
Indications — required:
Nonsevere acute pain — low back pain, sprains, or minor to moderate injuries without signs of major tissue damage
“Routine opioid use is strongly not recommended for the treatment of nonsevere acute pain (e.g., low back pain, sprains, or minor/moderate injuries without signs of major tissue damage).” — p. 25
STRONGLY not recommended at High confidence — the firmest position in the guideline. Its own examples of nonsevere acute pain are low back pain, sprains, and minor or moderate injuries without signs of major tissue damage.