Mitigating the Opioid Crisis for Wound Care Providers Using Opioid Stewardship

Robert George Smith, DPM, MSc, RPh


Wounds. 2020;32(6):146-151. 

In This Article

Abstract and Introduction


Opioids are an effective form of analgesia for pain treatment during wound treatment. Overprescribing of opioid agents has become detrimental to the public health of the United States. One of the most difficult challenges for any wound care prescriber is to balance the potential benefits versus the potential risks of opioid prescribing. Addressing the opioid crisis requires an interprofessional team approach. The utilization of an opioid stewardship program provides the necessary framework to identify gaps in the quality and development in the implementation of a change of long-standing opioid culture and practice. These programs address opioid prescribing, treatment for opioid use disorder, educational initiatives, and the use of information technology. A few acronyms have been created to assist providers to guide them when prescribing opioids. The purpose of this article is to explore the central theme of responsible opioid pain management. It will introduce, define, and defend with clinical-based evidence a proposed acronym, "MORPHINE," to assist and help shape prescription opioid strategies used for wound care treatment. Implications for practicing wound care specialists need to acknowledge the potential harm that prescribing opioids may cause to their patients.


Bechert and Abraham[1] reported that pain is often an overlooked factor in wound care and wound healing that affects wound care practice, and the nature of pain a patient experiences is directly related to the type of wound sustained. They,[1] along with others,[2] assert that pain is multidimensional and involves both physiological and psychological components. At the physiological level, wound pain develops from tissue damage or dysfunction of the nervous system. Chronic wound pain may be born of both nociceptive and neuropathic elements.[3] Wound pain is an individualized experience and differs from patient to patient based on their personal, familial, and cultural backgrounds, thereby leading to variations in a patient's experience and expression of pain. The wound care specialist may heed that pain is whatever the patient reports, and it needs to be addressed accordingly.

The World Union of Wound Healing Society's consensus document[3] categorizes wound pain as follows: (1) background pain or basal or baseline pain[1] is the continuous or intermittent pain felt by the patient even at rest, which includes pain associated with an infection; (2) incident pain or breakthrough pain[1] is described as pain that occurs during the patient's day-to-day activities, including during patient mobilization and even when the patient is coughing; (3) procedural pain is described as pain that results from routine procedures, such as dressing or ostomy pouch changes or wound cleaning; and (4) operative pain is described as the pain associated with significant wound interventions, including wound debridement and wound biopsy. Operative pain may be severe enough to require anesthesia.[3]

The National Institutes of Health Interagency Pain Research Coordinating Committee has asserted that "when opioids are used as prescribed and appropriately monitored, they can be safe and effective for acute, postoperative, and procedural pain, as well as for patients near the end of life who desire more pain relief."[4] Opioids are an effective form of analgesia for pain treatment. Overprescribing of opioids due to the prescriber's lack of knowledge about different opioid molecules and available technologies has become rampant in the United States. One of the most difficult challenges for medical providers is balancing the potential benefits and risks of opioid prescribing. An interprofessional team approach is required to curtail the opioid crisis. The adoption of an opioid stewardship program (OSP) provides the necessary framework to identify gaps in quality, development, and implementation to alter the long-standing opioid culture and practice.[5–7] Sandbrink and Uppal[5] assert in their commentary the need for an opioid stewardship model as presented and detailed by Weiner et al.[7] First, the program should encourage the use of non-opioids as first-line treatment programs.[6] Subsequently, these programs should provide pathways for safer opioid use when opioids are indicated.[6] Lastly, these programs should identify patients with opioid use disorders and engage them in treatment.[6]

These programs address opioid prescriptions, treatment for opioid use disorder, educational initiatives, and the use of information technology. The wound care specialist can appreciate the concept of opioid stewardship, the origins and principles of which are in currently established antimicrobial stewardship accepted across practices. The following 7 fundamental actions support the practice of opioid stewardship within the interprofessional health care arena: (1) promotion by leadership to commit to change in the existing culture; (2) implementing organizational policies; (3) advancement of clinical knowledge, expertise, and practice; (4) enhancement of patient and family caregiver education; (5) tracking, monitoring, and reporting performance data; (6) establishment of accountability; and (7) supporting a network through community collaboration.[8]

The clinical literature reports that link legitimate opioid prescriptions with opioid misuse, abuse, and opioid diversion are available. Any surgical intervention procedure represents a potential gateway to opioid dependence, and clinicians treating lower extremity wounds must recognize and develop methods as they embrace their role as stewards of safe opioid use. Given that opioid overdoses have increased over the last decade, it is imperative that physicians who specialize in wound care assume ownership of their role in curtailing opioid misuse and abuse.

A few acronyms have been created to assist providers in guiding them when prescribing opioids.[9,10] The central theme of this review is responsible opioid pain management. It will introduce and define the acronym "MORPHINE" to assist during opioid prescribing to treat pain. Each letter of the acronym MORPHINE stands for an essential principle of opioid stewardship. Clinical-based evidence will be presented to defend the use of the MORPHINE acronym by providing an argument highlighting current ethical prescribing standards and legal regulations in the context of opioid stewardship principles aimed at alleviating the widespread opioid crisis that wound care providers face daily.