Opioid Prescribing Guidelines

Introduction to Opioid Prescribing

The National Comprehensive Cancer Network recommends hydrocodone combination products as the most commonly prescribed opioid pain medications in the United States 1, 2
The American College of Physicians and other organizations suggest that non-opioid analgesics, such as acetaminophen and NSAIDs, are first-line treatments for mild pain 3, 4

For mild pain, the World Health Organization (WHO) recommends non-opioid analgesics, including acetaminophen and NSAIDs, as first-line treatments 3, 4
For moderate pain, the National Comprehensive Cancer Network suggests hydrocodone combination products, codeine combined with acetaminophen, tramadol, and low-dose oxycodone with acetaminophen as treatment options 1, 3, 5
For severe pain, the WHO recommends morphine as the standard preferred starting drug, with other strong opioids like oxycodone, hydromorphone, and fentanyl also being used 1, 5, 6

The Centers for Disease Control and Prevention (CDC) provides conversion factors to compare the potency of different opioids, including hydrocodone, oxycodone, morphine, hydromorphone, codeine, tramadol, and fentanyl 7, 8
The CDC recommends starting opioid-naïve patients with the lowest effective dose, typically equivalent to 20-30 Morphine Milligram Equivalent (MME)/day, and exercising caution when prescribing opioids at any dosage 7

The National Comprehensive Cancer Network advises careful reassessment before increasing total opioid dosage to ≥50 MME/day and avoiding dosage increases when possible 7
The CDC recommends recognizing the risks of dependence, addiction, and abuse associated with hydrocodone and other opioid products, as well as the potential for physical dependence and drug-seeking behavior 1, 7
The American College of Physicians suggests avoiding common pitfalls, such as failing to recognize codeine's variable effectiveness due to CYP2D6 enzyme polymorphism and using transdermal fentanyl for rapid opioid titration 1