Avoid using opioids for treatment of mild, acute pain. For moderate to severe acute pain, if opioids are used, it should be in conjunction with non-opioid methods with the lowest effective dose for the shortest required duration.
Opioids have serious risks including opioid use disorder and overdose. If opioid therapy is required, pain management with short acting opioids should be the lowest effective dose for the shortest required duration, often no more than 1 week. A trial of non-opioid and non-pharmacological alternatives is recommended for opioid naïve patients. If opioids are used, they may be used in conjunction with non-opioid methods, when clinically appropriate. For patients already on opioids for chronic pain, it is not recommended to abruptly stop or taper opioid therapy to avoid withdrawal, mental health crisis, and overdose. Individualized treatment plans should be made with the patient and outpatient clinicians, whenever possible. It is important for the clinician to assess potential biases that may affect treatment of pain.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
The Society of Hospital Medicine (SHM) created a Choosing Wisely® subcommittee comprised of representatives of the Hospital Quality and Patient Safety committee and included diverse representation of academic, community and adult hospitalists. SHM committee members submitted 150 recommendations for consideration, which were discussed for frequency of occurrence, the uniqueness of the tests and treatments and whether the cost burden for a specific test or treatment proved to be significant, narrowing the list to 65 items. The Choosing Wisely subcommittee ranked these items and a survey was sent to all SHM members to arrive at 11 recommendations, of which the final five were determined utilizing the Delphi method. SHM’s Board approved the final recommendations.
These recommendations were created by the SHM Hospital Quality and Patient Safety Committee’s High Value Care Sub-Committee (HVCC).
Phase 1: Crowdsourcing and Brainstorming – An online questionnaire requesting examples of low-value care in adult hospital medicine was sent to the SHM listserv, along with ABIM Foundation and affiliated social media outlets. All examples of low-value care from the questionnaire were compiled, edited, counted, and categorized into 5 domains: laboratory, imaging, medication, diagnostics and other. Duplicate or similar recommendations were also taken into account. Recommendations in the previous SHM CW Top 5 list were removed. All items with 10 or more mentions were taken into the next phase in an effort to capture the most prominent themes.
Phase 2: Literature Search and Developing Recommendations – All items brought into this phase were individually reviewed and discussed through an iterative process. Items were divided among HVCC members, and a literature search was performed in the PubMed database. Focused recommendations were developed and presented to the committee for review. Items that were duplicative or had insufficient evidence to support the recommendation were removed, leaving 22 items.
Phase 3: Modified Delphi Voting – For the remaining recommendations, a Delphi scoring process was utilized to reach consensus among clinicians and patient advocates. A total of 7 HVCC members and 7 patient advocates voted on the recommendations.
For each recommendation on the voting survey, clinician respondents were asked to rate on a 1-5 Likert scale on three criteria: (1) strength of evidence, (2) potential for avoiding patient harm, and (3) relevance to hospital medicine. Patient advocates were asked to rate each recommendation based on the same Likert scale on a slightly different criteria: (1) strength of evidence, (2) potential for avoiding patient harm, and (3) relevance to patients.
SHM’s disclosure and conflict of interest policy can be found at www.hospitalmedicine.org/industry.
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Hachimi-Idrissi S, Dobias V, Hautz WE, et al. Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations. Intern Emerg Med. 2020;15(7):1141-1155. doi:10.1007/s11739-020-02411-2
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021;326(5):411-419. doi:10.1001/jama.2021.11013