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

O: Opioid Formulary

"O" stands for the development of an opioid formulary. An opioid stewardship program can limit opioid initiation by creating prescribing guidelines.[6,7] Wound care specialists can create their own opioid formulary by rigorously and regularly administering 1 or 2 drugs for each clinical condition they commonly encounter. First, clinicians should use primary literature sources to include peer-reviewed, randomized, double-blinded clinical trials that compare medications. Subsequently, they may use secondary literature sources to include "Drug Facts and Comparisons" and "The Medical Letter on Drugs and Therapeutics" as well as review articles in peer-reviewed journals when comparing drug classes and to review recommendations centered around appropriate drug choice. Important considerations for objective opioid selection include drug efficiency, safety, patient acceptability, and cost. No single opioid analgesic may be perfect, and no single agent can treat all types of pain. Morphine-equivalent tables have been developed, and their purpose is to assist clinicians in determining equianalgesic doses of various opioid agents when changing or rotating opioid therapy. Opioid equianalgesic doses are presented in Table 1.

The underlying rationale for adopting combination strategies includes the availability of individual agents that induce analgesia through separate or overlapping mechanisms or that have separate adverse effects. The basic goal of a combination strategy is to amplify the desired effects while decreasing, or at least not equally increasing, the undesired effects in the individual agents. Second, when the pain is not controlled by initial medications, the addition of an opioid—for example, codeine—or the prescribing of tramadol or of an adjuvant agent is appropriate and within the principles of opioid stewardship.[1,17] The last step of the WHO approach is when the patient's pain does not respond to the second-step medications and the clinician needs to discontinue the initial drug; in such cases, a more potent oral narcotic should be initiated.[1]