opioid prescribing practices

Epidemiology

• overuse of prescription opioids by adults 25-64 years of age
• 15% of emergency department visits & 3% of clinic visits result in an opioid prescription
• opioid precriptions to Medicaid patients in the emergency department associated with 4-fold risk of opioid abuse after discharge
• opioid prescribing > 40% for dental procedures in all ages
• ~ 1/2 of opioid-naive inpatients given an opioid during hospitalization
• family members of patients prescribed opioids at increased risk for opioid overdose
• whites more likely to recieve opiates than persons of other races
  • cognitive impairment, age > 95 years, black or Asian race less likely to receive opiate

Laboratory

• urine drug screen
  • prior to starting opioid
  • high risk patients
  • annual urine drug screen with refills sufficient in low-risk patients

Complications

• persistent opioid use rare among opioid-naive adults receiving opioid for acute pain in the emergency department
• daytime sleepiness in patients on chronic opioid therapy suggests obstructive &/or central sleep apnea

Management

cautionary notes

• patients with chronic pain should be screened for depression & anxiety
• check polysomnography prior to escalating opioid dose in patients with suspected sleep disorder
• review state prescription monitoring database when starting or refilling opioid prescriptions
  • a patient taking opioids obtained from friends or family is opioid abuse
    • avoid prescribing opioids unless a taper to discontinuation is indicated.
• when precribing opioids to an opioid-naive person or increasing the dose of currently prescribed opioid, caution the patient to avoid driving or engaging in activities requiring heightened attention for at least 1 week
• consider prescribing or co-prescribing naloxone to high-risk patients receiving opiates, including those receiving >= 50 mg of morphine equivalents/day

non-cancer pain

• chronic opioid therapy should be provided
  • in low doses
  • with appropriate adherence monitoring
  • with understanding of adverse events
  • to patients with proven medical necessity
  • to patients who demonstrate stable improvement in both pain relief & activities of daily living
  • either independently or in conjunction with other treatment modalities

acute pain, starting opioids

• when starting analgesia, consider the pain ladder
  • acetaminphen & NSAIDs are at the bottom of the ladder
• when starting opioid prescriptions, start with short-acting formulation
  • for most patients with non-cancer pain short-acting opiates are preferable
  • for acute pain prescribe short-acting opiate for no more than 3 days

transition to chronic use

• if long-term use anticipated, transition to sustained release formulation when stable dose achieved
• start daily sustained release opiate at the equivalent dose of the daily short-acting opiate while maintaining the short-acting opiate PRN for breakthrough pain
• severe, acute pain in patients with cirrhosis is best managed with low-dose intravenous hydromorphone or intravenous fentanyl
• for severe pain not response to non-opioid analgesics in patients taking buprenorphine/naloxone, split buprenorphine/naloxone dose & prescribe short-acting opioid for no more than 3 days

acute on chronic pain

• continue current dose of long-acting opioid
  • add short-acting opioid if non-opioid analgesics unsatisfactory
    • dose usual starting dose for short-acting opioid

chronic pain, maintenance opioids

• consider prescribing or co-prescribing naloxone to high-risk patients receiving opiates, including those receiving >= 50 mg of morphine equivalents/day
• breakthrough doses should be ~10% of total daily dose or 1/3-1/4 the single sustained-release dose of morphine PO
  • as often as hourly (GRS)
  • every 3-4 hours (NEJM)
• when a patient on a stable dose of long-acting opioid has inadequate pain relief or intolerable adverse effects, consider a different long-acting opioid at a lower morphine milligram equivalent (25-75%) (opioid rotation)
  • rule out disease progression, diversion, opioid abuse
• if a patient on chronic opioid therapy compliant with prescribed opioids forgets to bring medications on vacation, requests replacement supply due to symptoms of withdrawal, prescribe sufficient opioid at the current dose for the vacation & adjust her next prescription to account for vacation supply
• if a patient is improving on a PRN opioid regimen & not using all of the prescribed opioid, continue current regimen
• if a patient is compliant, pain is well-controlled, no evidence of opioid abuse, continue current regimen
• if a patient expresses interest in reducing or stopping opioids, a dose reduction plan (taper) should be discussed
• if repeat urine drug screen shows patient is not taking prescribed opioid, discontinue opioid & offer non-opioid analgesic(s)
• if member of the household could be using patient's medications, recommend a lockbox for storage of controlled substances
• if previously compliant patient takes extra extended-release opioid on stressful days, assess understanding, review treatment plan, prescribe 1 time early 2 week supply
• patients on stable doses of extended release opioid for chronic pain who can no longer take oral medications may benefit from transdermal fentanyl or buprinorphinne plus liquid opioid through G-tube for breakthrough pain

opioid overdose/adverse effects

• if evidence of opioid overdose, somnolence, respiratory depression, pinpoint pupils, reduce opioid dose
  • consider regional anesthesia, ketamine, lidocaine (intravenous vs topical), NSAIDs, acetaminophen, gabapentenoids
• if opioid is controlling pain but may be inducing delirium, reduce opioid dose, reorient patient & consider non-opioid analgesia

opioid taper

• FDA provides guidelines for safely tapering the drugs in patients who are physically dependent on them
  • one taper schedule does not fit all
  • in general taper by no more than 10-25% every 2 -4 weeks
  • patients should be monitored for suicidality, substance misuse, & mood changes during tapering [[1]
• when inheriting patients on opioids
  • continue opioid therapy for patients in transition
  • develop a patient-centered, individualized care plan
  • use caution when tapering opioid therapy
  • document patient care decisions
  • prescribe buprenorphine when appropriate

opioids safe in renal insufficiency

• hydromorphone
• fentanyl
• methadone (long-acting only)

concerns of addiction

• explain
  • physical dependence is common
  • psychological addition is rare in patients at low risk of opioid use disorder
• ask about specific concerns of addiction

Notes

• physicians who received speaking fees, meals, & other non- research payments are more likely to prescribe opioids
• 29% of opioid prescriptions written without documentation of pain diagnosis
• CDC guidelines have reduced opioid prescribing
• long-term opioid use accounts for majority of opioid use in Medicare population
• larger opioid prescriptions after surgery, associated with more opioid use

Additional terms

• opiate
• opioid receptor agonist (narcotic)

Patient information

opioid prescribing practices patient information