As powerful analgesics against chronic and severe pain, opioids play an important role in outpatient procedures. Morphine is still the most widely used opioid in the hospital setting, experts say, but a range of choices are available depending on the duration of the pain and patients' differing reactions to particular medications (see "Your Opioid Choices").

At most ambulatory surgery facilities, opioids are primarily administered intravenously (pre- and intraoperatively) or orally (post-operatively), and formulated in potency from short-acting drugs such as codeine and hydromorphone to the longer-acting morphine sulfate (MSContin, Kadian) or oxycodone HCI (OxyContin). How should you choose the opioids your facility will need? We asked pain medication experts to weigh in.

Go with what you know
"Obviously, you want to consult with your physicians," says Alan P. Marco, MD, MMM, quality medical liaison for the Medical College of Ohio in Toledo. "Physicians tend to use what they're familiar with, and with good reason. If you know the dosage and are familiar with the results, that's patient safety."

Also try to ascertain what you might not need. "You don't want to get caught up in ordering all the newest, greatest drugs on the market if your physicians aren't using them," says Pamela Palmer, MD, PhD, medical director for the University of San Francisco Medical Center at Mount Zion Pain Management Center.

Maintain alternatives
"There are so many people who have idiosyncratic reactions to opioids," says Dr. Palmer. "There has got to be a choice in the marketplace. There can't be just one drug."

Research has shown the effects of opioids differ depending on patients' genetic structures and the receptors in their central nervous system. In addition to the risks of dependence and tolerance, opioids can also lead to such side effects as post-operative nausea or ileus, sedation, respiratory depression or renal damage. Since administering opioids can be a trial-and-error process, it is important to stock alternatives.

"Morphine is not the greatest opiate," remarks Dr. Palmer. "I wouldn't pick morphine. It has a lot of side effects, it causes a lot of nausea and the elderly can have particular problems with it."

Hydromorphone and fentanyl, on the other hand, are "cleaner opiates," she says, injectables with fewer side effects that should also be kept on hand. The three drugs "are the universal basics," says Gerald McGrory, RPh, pharmacy director for Phoenixville Hospital in Phoenixville, Pa. "They cover the vast majority, 97 or 98 percent, of all the patients we see."

Firm up your formulary
It's not advisable to get too inclusive, though, Dr. Palmer notes. "Many opioids are the same, but have different durations," she says.

"There are only so many opioids," agrees Dr. Marco. "You'll want representative classes, but do you need fentanyl, alfentanil, sufentanil and remifentanil? I would say probably not," unless a particular specialty at your facility benefits from the drugs' varying durations.

"Even if it's not a huge cost (for an infrequently used drug), there's a cost in stocking and inventory management," he says. "Narrow your focus, and you won't have to stock so many items. Reduce the number of similar products just as you'd reduce the number of orthopedic implants you stock." He recommends consulting physicians on what they need.

Mr. McGrory's hospital asks quarterly. Phoenixville Hospital's drug utilization review calculates how often each medication is prescribed and recommends to the hospital's governing committee products to be deleted or suspended from the formulary.

Another review happens automatically. "When new products come on the market," says Mr. McGrory, "we have to figure out if they have an advantage over the ones we already carry." Recent new opioid products have been promising longer durations and combinations with ibuprofen instead of acetaminophen, he says. Mr. McGrory isn't sold. "The new ones, there's not too much advantage over what we have now," he says.

Count the costs
The reviews that Mr. McGrory describes follow a pharmoeconomic approach, he says. First, a drug's efficacy is considered, then its cost. "Some of the newer drugs that are coming on the market, the expense would prevent us from putting them on the formulary," says Mr. McGrory.

Looking at a new opioid product, says Dr. Marco, "I would ask myself what it's comprised of." If it's made up of the same components as existing drugs - codeine and acetaminophen, for instance - you might want to stick with what you're using, or consider generic formulations.

"If it's FDA-approved, it's the same, no matter who makes it," he says. "Work on your best deal, because the products are going to be the same. If it's a different vehicle, though, you have to ask yourself, what's making this worth the cost?" says Dr. Marco.

Unavoidably, cost is a factor in choosing - or not choosing - opioids. "If you could reduce your dependence on opioids, that would be great, but morphine is cheap," he says. Given the side effects of opioids, though, he admits the advantages of using them in conjunction with nerve blocks or non-steroidal anti-inflammatory drugs. "There's not too much in cost savings, but if you don't have to treat PONV, that's a cost savings there. There's value in improved patient care."

Bring the right tools
When a facility orders opioids, the decision is often based on case mix, says Mr. McGrory. "They're going to assess what type of surgeries they're going to be seeing, and that would determine the potency of the drugs they'd need."

But will they be potent enough? Dr. Palmer points out that stocking the right drugs can make pain management more efficient. For post-op and post-discharge pain, Vicodin and Percocet are mainstays, she says. As more major procedures are done outpatient, such as orthopedic and abdominal cases, she warns against prescribing what's traditionally administered for minor surgery. "That's going to be some pretty significant pain. It doesn't make sense to have them taking painkillers every two or three hours," she says.

"People are starting to realize that drugs for chronic pain are also good for treating pain after surgery," adds Dr. Palmer. "Some enlightened surgeons are sending them home with OxyContin, for example, which lasts eight hours to 12 hours."

Consider new methods
That's why Dr. Palmer sees promise in fentanyl transdermal patches, which can deliver a steady flow of analgesic relief over 72 hours. In her view, they offer a bridge between epidural removal and when major pain begins to subside.

"Slip it on after surgery, before they go home, and three days later they can convert to the Vicodin," she says. "It's like having an IV drip at home."

"Topical patches are going to be utilized much more frequently in the future," says Mr. McGrory, although he notes that at present, the fentanyl patch's lowest available dose is 25 micrograms per hour, too large a dose for elderly patients.

Patches with different dosages, durations and opioid drugs are currently being developed, Dr. Palmer says, as are patient-controlled opioid patches that incorporate a tiny battery and a button that patients would press to administer a dose.

"That's going to be phenomenal for outpatient surgery use," she says. "Patient-controlled variability will give us a wider range of options."

But Mr. McGrory doesn't see that happening immediately. "It's a nice idea, but I think we won't see that for another three years or so," he says, citing the interference the patch's battery could cause with pacemakers and other electronic medical devices.

Examine your role
In Dr. Marco's view, however, you might not want to stock your formulary with too many post-op pain options. "Do you want to be a pharmacy? That's the question I'd ask myself," he says. "Those are outpatient medications, and you're doing outpatient procedures. Why should you pay for them?"

He suggests keeping enough Vicodin or Percocet on hand for the patients' first post-op, pre-discharge doses, but not too much more than those basics. "You want to think about your process, and get comfortable with sending them out the door with a prescription in hand" that they can have filled on the way home, says Dr. Marco.

Mr. McGrory disagrees. "It's recommended that surgery facilities stock some opioids they can initially give to patients," he says. "Patients need to be able to take them right away and not as the pain's starting again." Additionally, patients might not be able to get a prescription filled after surgery, and family members might be prohibited by law from obtaining an opioid prescription in their absence.

In that case, Dr. Marco says, ask your physicians to prescribe the patient's post-op pain medications at the pre-op office visit, so the prescription can be filled ahead of time. "They can even bring it along on the day of surgery," he says.