SHM releases recommendations on opioid use in hospitalized adults with acute, noncancer pain

Clinicians should pair opioids with scheduled nonopioid analgesics, unless contraindicated, and always consider nonpharmacologic pain management strategies, according to the consensus statement from the Society of Hospital Medicine.


The Society of Hospital Medicine (SHM) recently released a consensus statement that includes 16 recommendations on the use of opioids in hospitalized adults with acute, noncancer pain.

The consensus statement, which was based on a systematic review of relevant guidelines, applies to patients who are not in palliative, end-of-life, or intensive care settings. The full list of recommendations was published in the April 2018 Journal of Hospital Medicine.

Notable recommendations include the following:

  • Clinicians should limit the use of opioids to patients with either severe pain or moderate pain that has not responded to nonopioid therapy or where nonopioid treatment is contraindicated or anticipated to be ineffective.
  • When using opioids, use the lowest effective dose for the shortest possible duration. To treat acute pain, use immediate-release formulations and avoid long-acting or extended-release formulations, including transdermal fentanyl.
  • Use oral opioids whenever possible. IV opioids should be reserved for patients who cannot take food or medications by mouth, those who may have gastrointestinal malabsorption, and when immediate pain control and/or rapid dose titration is necessary.
  • When initiating opioid therapy, changing from one route of administration to another, or changing from one opioid to another, use an opioid equivalency table or calculator.
  • Clinicians should pair opioids with scheduled nonopioid analgesic medications, unless contraindicated, and always consider using nonpharmacologic pain management strategies.
  • To prevent opioid-induced constipation, clinicians should order a bowel regimen, such as stimulant laxatives, for all hospitalized patients receiving opioids (unless contraindicated). Stool softeners are not recommended.
  • Limit coadministration of opioids with other central nervous system depressant medications to the extent possible.
  • At the start of opioid therapy, clinicians should educate patients, families, and caregivers about the potential risks and side effects, as well as establish realistic goals and expectations for recovery.
  • If issuing an opioid prescription at discharge, clinicians should ask patients about any existing opioid supply at home and account for any such supply. They should prescribe the minimum quantity of opioids anticipated to be necessary.
  • At discharge, clinicians should also ensure that patients, families, and caregivers receive information on how to minimize the risks of opioid therapy (e.g., taking opioids correctly, taking the minimum quantity necessary, safeguarding their supply and disposing any unused supply, and avoiding agents that may potentiate sedative effects).