Primary prevention

The US Centers for Disease Control and Prevention (CDC) guidelines for safe opioid prescribing are key to primary prevention of opioid use disorder.[37] The following points are a summary of the CDC guidelines for prescribing opioids for pain:

  • Consider and maximise non-opioid medications and behavioural interventions first

  • Prioritise non-opioid therapies for subacute and chronic pain

  • Before starting an opioid for subacute or chronic pain, establish and measure goals for function and pain, and plan to discontinue therapy if benefits do not outweigh risks

  • Discuss risks, benefits, and responsibilities before and during opioid therapy

  • Use immediate-release opioids while starting opioids for acute, subacute, and chronic pain

  • For opioid-naive patients, prescribe the lowest effective dosage, and only increase the dosage (if required) with caution

  • For patients already on opioid therapy, review the risks versus benefits of continuing treatment, and optimise non-opioid therapies and/or taper down and/or discontinue opioid treatment as appropriate

  • Do not discontinue opioid therapy abruptly unless there are indications of a life-threatening issue (e.g., impending overdose)

  • For acute pain, prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids

  • Evaluate benefits and risks with patients within 1 to 4 weeks of starting opioid therapy for subacute or chronic pain or of dose escalation, and regularly review the need for continued treatment

  • Agree on risk-mitigation strategies with patients continuing opioid therapy, including offering naloxone

  • Evaluate risk of overdose by reviewing the patient's history of controlled substance prescriptions before prescribing an opioid for any type of pain, and periodically during therapy for chronic pain; in the US this can be done using state prescription drug monitoring program (PDMP) data

  • Consider toxicology testing to assess for prescribed medications/controlled substances before prescribing an opioid for subacute or chronic pain

  • Use particular caution when prescribing an opioid and benzodiazepine concurrently

  • Consider whether benefits outweigh risks of concurrent prescribing of opioid and other central nervous system depressants (e.g., gabapentin, pregabalin, muscle relaxants, sedating hypnotics)

Regarding cancer-related pain, the American Society of Clinical Oncology (ASCO) offers the following guidance on the use of opioids to manage pain from cancer or cancer treatment in adults:[38]

  • Offer opioids to patients with moderate-to-severe pain related to cancer or active cancer treatment, unless contraindicated

  • Initiate opioid on a PRN (as needed) basis, at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration

  • For patients with a pre-existing substance use disorder, clinicians should collaborate with palliative care, pain, and/or substance use disorder specialists to determine the optimal approach to pain management.

Primary prevention in adolescents may include strategies to limit risk factors such as childhood trauma. Evidence from randomised controlled trials shows that providing guidance to low-income, first-time mothers during pregnancy and in the first 2 years of a child's life through home visitation by nurses can have a range of lasting positive impacts on the child.[39] This includes reduced abuse and neglect, as well as greater cognitive and behavioural outcomes that extend into adolescence.[39] Community programmes focusing on developmental competencies, social skills, and resilience have also been shown to reduce prescription opioid misuse in US adolescents.[39]

Secondary prevention

Unsterile injecting practices and risky sexual behaviour among opioid users is a major contributor to the spread of HIV, hepatitis, and other infections.[189][190][191][192]

The US Centers for Disease Control and Prevention (CDC) recommends hepatitis A vaccination for injection and non-injection drug users (i.e., all those who use illicit drugs).[175]​​ The CDC also recommends universal hepatitis B vaccination in all adults aged 19 to 59 years.[175]​ In people 60 years of age or older, hepatitis B vaccination is recommended in the presence of additional risk factors, including current or recent injection drug use.[175]​​

The CDC recommends pre-exposure prophylaxis (PrEP) for HIV for adults and adolescents who inject drugs and report injection practices that place them at substantial ongoing risk of HIV exposure and acquisition (e.g., sharing needles).[174]

The American Society of Addiction Medicine recommends testing for tuberculosis, hepatitis, and HIV in all patients with opioid use disorder.[46] Investigations for other sexually transmitted infections should be considered: for example, rapid plasma reagin for syphilis.[46]

Psychosocial counselling and urine drug screen monitoring, as well as assessment and treatment of comorbid medical and psychiatric conditions (e.g., depression, anxiety disorders, and personality disorders), should occur as a part of maintenance therapy.[110] Drug therapy should be continued long term to prevent relapses.

People receiving chronic treatment with prescription opioids are 8- to 10-times more likely to initiate injection drug use, and so may benefit from enhanced efforts to prevent such initiation.[30]

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