FOR PRACTITIONERS

BEST PRACTICES FOR PRESCRIBING OPIOIDS

In 2013 there were 16,235 deaths from opioid analgesics; a four-fold increase from 1999. This increase is influenced by over-prescribing, patient non-adherence, unanticipated co-morbidities, and drug-drug interactions. Physicians, nurses, physician assistants, pharmacists, and program administrators can make an impact in decreasing opioid overdose and abuse rates in their communities. 

According to the CDC the benefits of long-term opioid therapy for chronic pain is not well supported by the evidence. Additionally, the short-term benefits related to pain are moderate and inconsistent for functioning. There is insufficient evidence that opioids have long-term benefits for low back pain, headache, and fibromyalgia. Yet opioids are very often prescribed for these purposes.

Below providers will find best practices in opioid prescribing, screening tools for risk of opioid abuse and misuse, recommendations for alternative therapies, and more.

For recommendations on opioid prescribing in specific situations (eg perioperative pain and non-cancer related pain) see the Interagency Guideline on Prescribing Opioids for Pain from the Agency Medical Director’s Group.

For prescribing guidelines from the CDC see their 2016 Guideline Information for Providers.

Major Reasons for Opioid Associated Death
  • Over-prescribing (Physician)

    • Starting dose too high

    • Dose escalation too rapid

    • Over reliance on conversion tables

    • Inadequate risk assessment

  • Non-adherence (Patient)

    • To control pain

    • To “cope”

    • Substance abuse

  • Unanticipated co-morbidities

    • QT prolongation

    • Pharmacogenetics & methadone

    • Sleep disordered breathing

    • metabolism

Eight Prescribing Principles for Providers

Providers’ Clinical Support System for Opioid Therapies

1) Assess patients for risk of abuse before starting opioid therapy and manage accordingly​

  • Individuals respond differently to opioid exposure. Genetic and environmental factors influence drug-abusing behavior.

  • Utilize existing tools when assessing patients (ORT, SOAPP, DIRE)

  • If the use of opioids is long term/ongoing periodically monitor for misuse. You may utilize screening tools (PADT, COMM), the state’s prescription drug monitoring system, and utilize urine testing.

2) Watch for and treat comorbid mental disease if present

  • There is a large overlap between patients who experience pain disorders and patients who experience psychiatric disorders (~50%). There is an even larger overlap in patients who experience both addiction disorders and psychiatric disorders. Co-occurrence of chronic pain and mental health disorders place the patients at high risk for misuse, drug-drug interactions, and overdose.

  • Care must be taken when prescribing opioids and care should be coordinated.

3) Conventional conversion tables can cause harm and should be used cautiously when rotating (switching) from one opioid to another.​

  • Equianalgesic tables provide insufficient guidance to determine the equivalent doses of different opioids.

  • Steps in opioid rotation:

    • Slowly decrease one opioid while slowly titrating the new opioid to effect (there is more in the slides but I don’t understand)

    • In most cases, the complete switch can occur within 3-4 weeks

    • If you are not experienced in switching opioids in patients on long-term opioid therapy, seek expert consultation

​4) Avoid combining benzodiazepines with opioids, especially during sleep hours

  • People who died of drug overdoses often had a combination of benzodiazepines & opioids in their bodies

  • Benzodiazepines enhance the respiratory depressant effects of opioids yet are frequently prescribed with opioids (up to 50% of patients)

  • Consider alternatives when prescribing for anxiety disorders and sleep aids

Treatment Services
Livingston

If you feel that a patient could benefit from Substance Use Disorder (SUD) treatment you can recommend they seek local treatment services by calling the Substance Abuse Coordinating Agency (also known as Access) at

(517) 546-4126

Those who live outside of Livingston Co., MI can find treatment services using this national treatment services locator. 

5) Start methadone at a very low dose and titrate slowly regardless of whether your patient is opioid tolerant or not​

  • Methadone contributed to nearly 1 in 3 prescription opioid deaths in 2009

  • Consider starting patients, whether or not they are opioid naïve, on ≤15 mg/day in divided doses (qh8)

  • Increase the total daily dose by no more than 25%-50%, no more frequently than weekly

  • If you are not experienced prescribing methadone, consult with a clinician who is.

6) Assess for sleep apnea in patients on high daily doses of methadone or other opioids and in patients with a predisposition​

  • Refer the following patients for formal sleep apnea evaluation:

    • Patients who require >50 mg/day of methadone

    • Patients who require >150 mg/day of morphine equivalent dose of other opioids

    • Patients with a predisposition or risk factors for sleep apnea

    • At risk patients may require inpatient evaluation to monitor for & determine safety of opioid therapy

7) Tell patients on long-term opioid therapy to reduce opioid dose during upper respiratory infections or asthmatic episodes​

  • Because of a decreased margin of safety, advise patients to reduce their daily opioid doses by ≥30% during events with acute respiratory tract compromise including:

    • Flu

    • Pneumonia

    • Upper respiratory infections

    • Cigarette use

    • Chronic obstructive pulmonary disease

    • Asthmatic episodes

8) Avoid using long-acting opioid formulations for acute, postoperative, or trauma-related pain​

  • Reserve long-acting/extended-release opioids, including transdermal patches, for patients who have developed tolerance to opioids (ie, who already take regular, daily, around-the-clock opioids).

  • Do not use for acute, postoperative, or trauma-related pain.

Scope of Pain

Is a series of continuing medical education/continuing nursing education activities designed to help prescribers manage patients with chronic pain effectively and safely. 

Opioidprescribing.org offers an in-depth online program on effective communication skills as well as the potential risks and benefits of opioids and when and how to initiate, maintain, modify, continue or discontinue opioid therapy

Need more details? Contact Wake Up Livingston

We are here to help people get involved in ending the opioid epidemic.

Want to find out more about treatment?

Local treatment facilities are can help you recover.

Page material adapted from the following sources:​

Stepping Stones Engagement Center is a program of Livingston County Community Mental Health and funded by a grant through the Community Mental Health Partnership of Southeast Michigan.