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Applying Universal Precautions When Prescribing

Universal Precautions in Opioid Prescribing for Chronic Pain: The Time Has Come

Universal precautions in opioid prescribing for chronic pain are recommended. As yet, there is no empiric evidence of their effectiveness in reducing the abuse of prescription opioids or the outcomes related to the abuse, misuse, or diversion of prescription opioids.5 Although abuse-deterrent opioids do not address all types of abuse, including oral overconsumption, the risk for abuse is lower than it would be for opioids without such properties. Prescribing abuse-deterrent opioids is one step prescribers can take toward addressing the problem of abuse. However, there is still a risk of addiction, abuse, misuse, and diversion with these medications.11,12

Although there is considerable discussion about the use of prescription opioid therapy in the treatment of chronic pain, the application of universal precautions to patients being considered for or treated with opioid therapy for chronic pain has gained support.1-3,5,6,13 In this context, universal precautions are a set of uniform practices for prescribers, applied to every patient being considered for opioid therapy for chronic pain. These precautions are intended to help you gather and interpret information about the patient and make an appropriate treatment decision.5

The concept of universal precautions has its origins in infectious diseases and the need to address a patient’s potential infectivity on initial presentation.6,14 The rationale for applying universal precautions in the treatment of all patients being considered for opioid therapy for chronic pain is that it is difficult to predict who will misuse, abuse, or divert opioids, and also difficult to detect such behaviors in those already receiving treatment.7,15-17 While the application of universal precautions is certainly not a solution to the complex problem of prescription opioid abuse, it may be an important step in the right direction.6

With the aim of providing a guide for applying universal precautions in the clinical setting, a 4-step approach has been developed as part of this Rethink Opioids initiative, based on the available published literature.1-7,13

Within several of the steps, risk mitigation strategies are suggested that may facilitate the process of applying universal precautions when considering or prescribing opioid therapy. Collectively, the tools and resources provided can help support a comprehensive approach to patient assessment, monitoring, and treatment and mitigate the risk of misuse, abuse, and diversion.

Note that it is important to document your efforts as you complete the 4 steps with individual patients, to facilitate ongoing monitoring and also to help reduce your medicolegal exposure.6

Click ”Assess Risk” below to begin reviewing the 4 steps in order, or select a step from the menu on the left side of this page. For a printable flowchart of the entire 4-step process, see the Universal Precautions Implementation Tool.


  1. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130. PMID: 19187889
  2. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Version 2.0. Washington, DC: US Dept of Veterans Affairs, US Dept of Defense; 2010. Accessed November 6, 2017.
  3. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Noncancer Pain: An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010. Accessed November 6, 2017.
  4. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT: Utah Dept of Health; 2009. Accessed November 6, 2017.
  5. Webster LR, Fine PG. Approaches to improve pain relief while minimizing opioid abuse liability. J Pain. 2010;11(7):602-611. PMID: 20444651
  6. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112. PMID: 15773874
  7. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc. 2009;84(7):593-601. PMID: 19567713
  8. US Food and Drug Administration. ER/LA Opioid Analgesic Class Labeling Changes and Postmarket Requirements. Letter to ER/LA opioid application holders. Accessed November 6, 2017.
  9. Katz N, Dart RC, Bailey E, Trudeau J, Osgood E, Paillard F. Tampering with prescription opioids: nature and extent of the problem, health consequences, and solutions. Am J Drug Alcohol Abuse. 2011;37:205-217. PMID: 21517709
  10. Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2):131-146. PMID: 19187890
  11. US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research (CDER). Abuse-deterrent opioids; evaluation and labeling. Published April 2015. Accessed November 6, 2017.
  12. Stanos S. Continuing evolution of opioid use in primary care practice: implications of emerging technologies. Curr Med Res Opin. 2012;28(9):1505-1516. PMID: 22937723
  13. Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2—guidance. Pain Physician. 2012;15(3 suppl):S67-S116. PMID: 22786449
  14. Centers for Disease Control and Prevention. Perspectives in disease prevention and health promotion update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR Morbid Mortal Wkly Rep. 1988;37(24):377-388. PMID: 2836717
  15. Brown J, Setnik B, Lee K, et al. Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting. J Opioid Manag. 2011;7(6):467-483. PMID: 22320029
  16. Salinas GD, Susalka D, Burton BS, et al. Risk assessment and counseling behaviors of healthcare professionals managing patients with chronic pain: a national multifaceted assessment of physicians, pharmacists, and their patients. J Opioid Manag. 2012;8(5):273-284. PMID: 23247904
  17. Weiner SG, Griggs CA, Mitchell PM, et al. Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department. Ann Emerg Med. 2013;62(4):281-289. PMID: 23849618