Primary prevention
The 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 maximize nonopioid medications and behavioral interventions first
Prioritize nonopioid 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 optimize nonopioid 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 randomized 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 behavioral outcomes that extend into adolescence.[39] Community programs focusing on developmental competencies, social skills, and resilience have also been shown to reduce prescription opioid misuse in US adolescents.[39]
The table which follows summarizes recommendations for the primary prevention of opioid use disorder and opioid overdose, taken from the CDC clinical practice guidance for prescribing opioids for pain.[37]
Note that an individual patient may fall into more than one group, and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Outpatient ages ≥18 years; with acute pain (duration of <1 month); not already taking opioids
Excludes people with pain related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
All
Intervention
Maximize use of nonpharmacologic and nonopioid pharmacologic therapies
Ensure that acute pain is appropriately assessed and treated whether or not opioids are part of a treatment regimen.
Appropriate choice of treatment is individualized, and varies according to the specific source of acute pain.
Nonpharmacologic therapies to consider include:
Ice
Heat
Elevation
Rest
Immobilization
Exercise
Nonopioid pharmacologic therapies to consider include:
Topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs)
Acetaminophen
NSAID use has been associated with serious gastrointestinal events and major coronary events, particularly in people with cardiovascular or gastrointestinal comorbidities, and it is recommended that clinicians weigh risks and benefits of use, dose, and duration of NSAIDs when treating older adults as well as patients with comorbidities such as hypertension, renal insufficiency, heart failure, or those with risk for peptic ulcer disease or cardiovascular disease.
If using an NSAID, use at the lowest effective dose and for the shortest required duration is recommended, in order to minimize the risk of treatment-associated harm.
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Benefits of opioid treatment are not anticipated to outweigh risks
Intervention
Continue nonopioid treatment for acute pain
As a general rule, opioid therapy is not advised for many common acute pain conditions, for which nonopioid treatments are equally effective or more effective than opioids.
This includes:
Low back pain
Neck pain
Pain related to other musculoskeletal injuries (e.g., sprains, strains, tendonitis, and bursitis)
Pain related to minor surgeries (e.g., simple dental extraction)
Dental pain
Kidney stone pain
Headaches including episodic migraine
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Benefits of opioid treatment are anticipated to outweigh risks
Intervention
Consider short-term opioid therapy for acute pain; offer patient education for opioid risk mitigation; consider offering naloxone
Only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient.
Opioid therapy may be considered for some types of severe acute pain, including when NSAIDs and other therapies are contraindicated or likely to be ineffective.
It is recommended that clinicians involve patients meaningfully in decisions about whether to start opioid therapy.
Ensure that patients are aware of the following before starting opioid therapy:
The expected benefits
The common risks
The serious risks
Alternatives to opioids
Before starting opioid therapy, evaluate the risk for opioid-related harms (medical, mental health and substance use disorder-related) and discuss risk with patients.
Ideally, clinicians should review state PDMP data before every opioid prescription for acute, subacute and chronic pain, to determine whether the patient is receiving opioid dosages or combinations that put them at high risk for overdose.
Consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants. Use particular caution when prescribing opioids concurrently to a patient already receiving benzodiazepines, understanding that this may be warranted in certain select clinical circumstances. Communicate with others managing the patient to weigh up the risks and benefits of concurrent treatment.
When starting opioid therapy, prescribe immediate-release and short-acting formulations instead of extended-release and long acting formulations.
Patient education for opioid risk mitigation:
Educate patients on overdose prevention and naloxone use (see below) and offer to provide education to members of their households.
Discuss increased risks including opioid use disorder at higher dosages, along with the importance of taking only the amount of opioids prescribed (i.e., not taking more opioids than prescribed or taking them more often).
Consider offering naloxone:
Offer naloxone when prescribing opioids, particularly to patients at increased risk for overdose, including those:
With a history of overdose
With a history of substance use disorder
With sleep-disordered breathing (but note that it is recommended that clinicians avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing when possible to minimize risk for respiratory depression)
Taking higher doses of opioids (e.g., ≥50 morphine milligram equivalents [MME] daily)
Taking benzodiazepines concurrently with opioids
Resources for prescribing naloxone in primary care and emergency department settings can be found through Prescribe to Prevent. PrescribeToPrevent: Prescribe Naloxone Save a Life Opens in new window
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Pain and functional goals:
To help patients assess when a dose of an opioid is needed, explain that the goal is to reduce pain to make it manageable rather than to eliminate pain.
Opioid minimization and harm reduction:
Prescribe the lowest effective dose and for no longer than the expected duration of pain severe enough to require opioids
This can be determined using the prescribing information as a starting point with calibration as needed based on severity of pain and other clinical factors such as renal or hepatic insufficiency
For opioid-naïve outpatients with acute pain treated with an opioid for a few days or less, dosage increases are usually unnecessary and should not be attempted without close monitoring
Prescribe and advise opioid use only as needed rather than on a scheduled basis
Duration of treatment is individualized to the patient’s clinical circumstances:
For many common causes of nontraumatic, nonsurgical pain, when opioids are needed, a few days or less are often sufficient
Longer durations of opioid therapy are more likely to be needed when the mechanism of injury is expected to result in prolonged severe pain (e.g., severe traumatic injuries)
If opioids are used continuously (around the clock) for more than a few days for acute pain, prescribe a brief taper to minimize withdrawal symptoms on discontinuation of opioids.
Re-evaluate patients at least every 2 weeks if they continue to receive opioids for acute pain.
For those who experience severe acute pain that continues longer than the expected duration, timely reevaluation to confirm or revise the initial diagnosis and adjust pain management is recommended.
Outpatient ages ≥18 years; with acute pain (duration of <1 month); already taking long-term opioids
Excludes people with pain related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
All
Intervention
Maximize use of nonpharmacologic and nonopioid pharmacologic therapies
If a patient already receiving opioids long term requires additional medication for acute pain, use nonopioid treatments where possible.
Appropriate choice of treatment is individualized, and varies according to the specific source of acute pain.
Nonpharmacologic therapies to consider include:
Ice
Heat
Elevation
Rest
Immobilization
Exercise
Nonopioid pharmacologic therapies to consider include:
Topical or oral nonsteroidal antiinflammatory drugs (NSAIDs)
Acetaminophen
NSAID use has been associated with serious gastrointestinal events and major coronary events, particularly in people with cardiovascular or gastrointestinal comorbidities, and it is recommended that clinicians weigh risks and benefits of use, dose, and duration of NSAIDs when treating older adults as well as patients with comorbidities such as hypertension, renal insufficiency, heart failure, or those with risk for peptic ulcer disease or cardiovascular disease.
If using an NSAID, use at the lowest effective dose and for the shortest required duration is recommended, in order to minimize the risk of treatment-associated harm.
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Benefits of opioid treatment are not anticipated to outweigh risks
Intervention
Continue nonopioid treatment for acute pain
As a general rule, opioid therapy is not advised for many common acute pain conditions, for which nonopioid treatments are equally effective or more effective than opioids. This includes:
Low back pain
Neck pain
Pain related to other musculoskeletal injuries (e.g., sprains, strains, tendonitis, and bursitis)
Pain related to minor surgeries (e.g., simple dental extraction)
Dental pain
Kidney stone pain
Headaches including episodic migraine
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Benefits of opioid treatment for acute pain are anticipated to outweigh risks
Intervention
Consider adding short-term opioid therapy for acute pain; offer patient education for opioid risk mitigation; consider offering naloxone
If additional opioids are required (e.g., for superimposed severe acute pain), it is recommended that they are continued only for the duration of pain severe enough to require additional opioids, returning to the patient’s baseline opioid dosage as soon as possible, including a taper to baseline dosage if additional opioids were used around the clock for more than a few days. If a taper is needed, taper durations might need to be adjusted depending on the duration of the initial opioid prescription.
It is recommended that clinicians involve patients meaningfully in decisions about whether to start opioid therapy.
Ensure that patients are aware of the following before starting additional opioid therapy:
The expected benefits
The common risks
The serious risks
Alternatives to opioids
Before starting additional opioid therapy, evaluate the risk for opioid-related harms (medical, mental health and substance use disorder-related) and discuss risk with patients.
Ideally, clinicians should review state PDMP data before every opioid prescription for acute, subacute and chronic pain, to determine whether the patient is receiving opioid dosages or combinations that put them at high risk for overdose.
In patients receiving opioids and benzodiazepines or other central nervous system depressants long-term, additional opioids may be associated with increased risks. Communicate with others managing the patient to weigh up the risks and benefits of additional short-term opioid treatment.
When starting additional opioid therapy, prescribe immediate-release, short-acting formulations.
Patient education for opioid risk mitigation:
Educate patients on overdose prevention and naloxone use (see below) and offer to provide education to members of their households.
Discuss increased risks including opioid use disorder at higher dosages, along with the importance of taking only the amount of opioids prescribed (i.e., not taking more opioids than prescribed or taking them more often).
Consider offering naloxone:
Offer naloxone when prescribing opioids, particularly to patients at increased risk for overdose, including those:
With a history of overdose
With a history of substance use disorder
With sleep-disordered breathing (but note that it is recommended that clinicians avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing when possible to minimize risk for respiratory depression)
Taking higher doses of opioids (e.g., ≥50 morphine milligram equivalents [MME] daily)
Taking benzodiazepines concurrently with opioids
At risk for returning to a high dose to which they have lost tolerance
Resources for prescribing naloxone in primary care and emergency department settings can be found through Prescribe to Prevent. PrescribeToPrevent: Prescribe Naloxone Save a Life Opens in new window
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Pain and functional goals:
To help patients assess when a dose of an opioid is needed, explain that the goal is to reduce pain to make it manageable rather than to eliminate pain.
Opioid minimization and harm reduction:
Prescribe the lowest effective dose and for no longer than the expected duration of pain severe enough to require opioids
This can be determined using the prescribing information as a starting point with calibration as needed based on severity of pain and other clinical factors such as renal or hepatic insufficiency
Prescribe and advise opioid use only as needed rather than on a scheduled basis
Duration of treatment for acute pain is individualized to the patient’s clinical circumstances:
For many common causes of nontraumatic, nonsurgical pain, when opioids are needed, a few days or less are often sufficient
Longer durations of opioid therapy are more likely to be needed when the mechanism of injury is expected to result in prolonged severe pain (e.g., severe traumatic injuries)
For those who experience severe acute pain that continues longer than the expected duration, timely reevaluation to confirm or revise the initial diagnosis and adjust pain management is recommended.
Re-evaluate patients at least every 2 weeks if they continue to receive opioids for acute pain.
Advise patients that there is an increased risk for overdose on abrupt return to a previously prescribed higher dose owing to loss of opioid tolerance.
Outpatient ages ≥18 years with subacute (duration of 1-3 months) or chronic (duration of >3 months) pain; not already taking opioids
Excludes people with pain related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
All
Intervention
Maximize use of nonpharmacologic and nonopioid pharmacologic therapies
Nonopioid therapies are preferred for subacute and chronic pain.
To guide patient-specific selection of therapy, it is important to thoroughly evaluate patients and establish or confirm the diagnosis.
Many noninvasive nonpharmacologic approaches can improve pain and function without risk for serious harms.
Recommend nonpharmacologic approaches to help manage subacute and chronic pain are highly individualized to the patient and according to the underlying diagnosis, and include (but are not limited to):
Exercise or exercise therapy
Weight loss (for knee osteoarthritis)
Behavioral therapies (e.g., cognitive behavioral therapy and mindfulness-based stress reduction)
Yoga, tai chi, and qigong
Massage
Acupuncture
Physical therapy
Nonopioid pharmacologic options are individualized to the patient, and vary considerably according to the underlying diagnosis.
See Osteoarthritis
See Musculoskeletal lower back pain
See Fibromyalgia
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Benefits of opioid treatment are not anticipated to outweigh risks
Intervention
Continue nonopioid treatment for subacute or chronic pain
Nonopioid therapies are preferred for subacute and chronic pain.
For some conditions (e.g., headache or fibromyalgia), the expected risks of initiating opioids are likely to outweigh the benefits regardless of previous nonpharmacologic and nonopioid pharmacologic therapies used.
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Benefits of opioid treatment are anticipated to outweigh risks
Intervention
Consider opioid therapy for subacute or chronic pain; offer patient education for opioid risk mitigation; consider naloxone
Opioids are not a first-line or routine therapy for subacute or chronic pain.
Weigh up the expected benefits specific to the clinical context against the risks before initiating therapy.
In some clinical contexts (e.g., serious illness in a patient with poor prognosis for return to previous level of function, contraindications to other therapies, and clinician and patient agreement that the overriding goal is patient comfort), opioids might be appropriate regardless of previous therapies used.
It is recommended that clinicians involve patients meaningfully in decisions about whether to start opioid therapy.
Ensure that patients are aware of the following before starting opioid therapy:
The expected benefits
The common risks
The serious risks
Alternatives to opioids
Before starting opioid therapy, evaluate the risk for opioid-related harms (medical, mental health and substance use disorder-related) and discuss risk with patients. When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
Ideally, clinicians should review state PDMP data before every opioid prescription for acute, subacute and chronic pain, to determine whether the patient is receiving opioid dosages or combinations that put them at high risk for overdose.
Consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants. Use particular caution when prescribing opioids concurrently to a patient already receiving benzodiazepines, understanding that this may be warranted in certain select clinical circumstances. Communicate with others managing the patient to weigh up the risks and benefits of concurrent treatment.
When starting opioid therapy, prescribe immediate-release formulations instead of extended-release formulations. Short-acting opioids are preferred over long-acting opioids.
Patient education for opioid risk mitigation:
Educate patients on overdose prevention and naloxone use (see below) and offer to provide education to members of their households.
Discuss increased risks including opioid use disorder at higher dosages, along with the importance of taking only the amount of opioids prescribed (i.e., not taking more opioids than prescribed or taking them more often).
Consider naloxone:
Offer naloxone when prescribing opioids, particularly to patients at increased risk for overdose, including those:
With a history of overdose
With a history of substance use disorder
With sleep-disordered breathing (but note that it is recommended that clinicians avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing when possible to minimize risk for respiratory depression)
Taking higher doses of opioids (e.g., ≥50 morphine milligram equivalents [MME] daily)
Taking benzodiazepines concurrently with opioids
Resources for prescribing naloxone in primary care and emergency department settings can be found through Prescribe to Prevent. PrescribeToPrevent: Prescribe Naloxone Save a Life Opens in new window
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Pain and functional goals:
Work with patients to establish treatment goals for pain and function, and consider how opioid therapy will be discontinued if benefits do not outweigh risks.
Emphasize improvement in function as a primary goal and that function can improve even when pain is not eliminated.
Ask patients about functional goals that have meaning for them, for example:
Walking the dog or walking around the block
Returning to part-time work
Attending family events or recreational activities
Assess and follow function, pain severity, and quality of life using tools such as the three-item PEG (Pain average, interference with Enjoyment of life, and interference with General activity) assessment scale.
Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function.
Opioid minimization and harm reduction:
Prescribe the lowest effective doseIf opioids are continued for subacute or chronic pain, use caution when prescribing opioids at any dosage and avoid dosage increases when possible
This can be determined using the prescribing information as a starting point with calibration as needed based on severity of pain and other clinical factors such as renal or hepatic insufficiency
If opioids are continued for subacute or chronic pain, use caution when prescribing opioids at any dosage and avoid dosage increases when possible
If a decision is made to increase dosage, use caution and increase by the smallest practical amount
Evaluate the benefits and risks with patients within 1-4 weeks of starting opioid therapy for subacute (or chronic pain) or of dosage escalation.
For patients with chronic pain:
Regularly reevaluate the benefits and risks of continued opioid therapy with patients. It is recommended that patients receiving long-term opioid therapy are assessed at least every 3 months, including ongoing review of PDMP data.
For patients with chronic pain and risk factors for opioid use disorder or overdose (e.g., those with depression or other mental health conditions, a history of substance use disorder, a history of overdose, taking ≥50 MME in 24 hours, or taking other central nervous system depressants with opioids), evaluation more frequently than every 3 months is recommended.
Outpatient ages ≥18 years with subacute (duration of 1–3 months) or chronic (duration of >3 months) pain; already taking opioids
Excludes people with pain related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
All
Intervention
Optimization of nonopioid treatment; reassessment of continued need for opioid treatment
Optimize nonopioid treatment (both nonpharmacologic and pharmacologic) as required.
Carefully weigh both the benefits and risks of continuing opioid medications and the benefits and risks of tapering opioids.
For patients with subacute pain who started opioid therapy for acute pain and have been treated with opioid therapy for ≥30 days, ensure that potentially reversible causes of ongoing pain are addressed and that opioid prescribing for acute pain does not unintentionally become long-term opioid therapy simply because medications are continued without reassessment.
Continuation of opioid therapy at this point might represent initiation of long-term opioid therapy, which should occur only as an intentional decision that benefits are likely to outweigh risks after informed discussion between the clinician and patient and as part of a comprehensive pain management approach.
In situations where benefits and risks of continuing opioids are considered to be close or unclear, shared decision-making with patients is particularly important.
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Pain and functional goals:
When reviewing a patient already receiving opioids, establish treatment goals, including functional goals, for continued opioid therapy.
Emphasize improvement in function as a primary goal and that function can improve even when pain is not eliminated.
Ask patients about functional goals that have meaning for them, e.g.,:
Walking the dog or walking around the block
Returning to part-time work
Attending family events or recreational activities
Assess and follow function, pain severity, and quality of life using tools such as the three-item PEG (Pain average, interference with Enjoyment of life, and interference with General activity) assessment scale.
Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function.
Periodic reassessment is required to ensure that opioids are helping to meet patient goals and, if opioids are not effective or are harmful, to allow opportunities for consideration of opioid tapering and dosage reduction or discontinuation and of additional nonpharmacologic or nonopioid pharmacologic treatment options.
Benefits of opioid treatment are not anticipated to outweigh risks
Intervention
Carefully taper opioids; offer patient education for opioid risk mitigation; consider naloxone
When benefits (including avoiding risks of tapering) do not outweigh risks of continued opioid therapy, it is recommended that clinicians optimize other therapies and work closely with patients to gradually taper to a reduced opioid dosage or, if warranted based on the individual clinical circumstances of the patient, appropriately taper and discontinue opioid therapy.
Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), do not discontinue opioid therapy abruptly, and do not rapidly reduce opioid dosages from higher dosages.
Some patients using more than one respiratory depressant (e.g., benzodiazepines and opioids) might require tapering from one or more medications to reduce risk for respiratory depression; co-ordinate tapering decisions and plans with prescribers of all respiratory depressant medications.
Remain alert to signs of and screen for anxiety, depression, and opioid misuse or opioid use disorder that might be revealed by an opioid taper and provide treatment or arrange for management of these comorbidities.
See Generalized anxiety disorder
Patient education for risk minimization:
Educate patients on overdose prevention and naloxone use (see below) and offer to provide education to members of their households.
Discuss increased risks including opioid use disorder at higher dosages, along with the importance of taking only the amount of opioids prescribed (i.e., not taking more opioids than prescribed or taking them more often).
Advise patients who are tapering opioids that there is an increased risk for overdose on abrupt return to a previously prescribed higher dose owing to loss of opioid tolerance.
Consider offering naloxone:
This is recommended for those undergoing tapering from opioids.
Resources for prescribing naloxone in primary care and emergency department settings can be found through Prescribe to Prevent. PrescribeToPrevent: Prescribe Naloxone Save a Life Opens in new window
Goal
Opioid minimization; individualized goal for taper; prevention of opioid use disorder and opioid overdose
Individualized goal for taper:
Goals of the taper may vary depending on the patient’s circumstances and an individualized assessment of benefits and risks:
Some patients might achieve opioid discontinuation
Others might attain a reduced dosage at which functional benefits outweigh risks
Patient agreement and interest in tapering is likely to be a key component of successful tapers; collaborate with the patient on the tapering plan, including patients in decisions such as how quickly tapering will occur and when pauses in the taper might be warranted.
At times, tapers might have to be paused and restarted again when the patient is ready and might have to be slowed as patients reach low dosages.
When opioids are reduced or discontinued, a taper slow enough to minimize symptoms and signs of opioid withdrawal (e.g., anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, or piloerection) is recommended.
Longer duration of previous opioid therapy might require a longer taper.
If the clinician has determined with the patient that the ultimate goal of tapering is discontinuing opioids, after the smallest available dose is reached the interval between doses can be extended and opioids can be stopped when taken less frequently than once a day.
Follow up frequently (at least monthly) with patients engaging in opioid tapering.
Benefits of continued opioid therapy are anticipated to outweigh risks
Intervention
Continue opioid therapy for subacute or chronic pain with periodic reassessment; offer patient education for opioid risk minimization; consider offering naloxone
Continue opioid therapy with periodic reassessment:
If the benefits outweigh risks of continued opioid therapy, work closely with patients to optimize nonopioid therapies while continuing opioid therapy.
Ensure that patients are aware of the following before continuing opioid therapy:
The expected benefits
The common risks
The serious risks
Alternatives to opioids
When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
Ideally, clinicians should review state PDMP data before every opioid prescription for acute, subacute and chronic pain, to determine whether the patient is receiving opioid dosages or combinations that put them at high risk for overdose. Consider the total morphine milligram equivalents (MME)/day for concurrent opioid prescriptions to help assess overdose risk.
Closely monitor patients who are unable to taper and who continue on high-dose or otherwise high-risk opioid regimens (e.g., opioids prescribed concurrently with benzodiazepines).
Patient education for opioid risk mitigation:
Educate patients on overdose prevention and naloxone use (see below) and offer to provide education to members of their households.
Discuss increased risks including opioid use disorder at higher dosages, along with the importance of taking only the amount of opioids prescribed (i.e., not taking more opioids than prescribed or taking them more often).
Consider offering naloxone:
Offer naloxone when prescribing opioids, particularly to patients at increased risk for overdose, including those:
With a history of overdose
With a history of substance use disorder
With sleep-disordered breathing (but note that it is recommended that clinicians avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing when possible to minimize risk for respiratory depression)
Taking higher doses of opioids (e.g., ≥50 MME daily)
Taking benzodiazepines concurrently with opioids
At risk for returning to a high dose to which they have lost tolerance
Resources for prescribing naloxone in primary care and emergency department settings can be found through Prescribe to Prevent. PrescribeToPrevent: Prescribe Naloxone Save a Life Opens in new window
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Pain and functional goals:
When reviewing a patient already receiving opioids, establish treatment goals, including functional goals, for continued opioid therapy.
Emphasize improvement in function as a primary goal and that function can improve even when pain is not eliminated.
Ask patients about functional goals that have meaning for them, e.g.,:
walking the dog or walking around the block
returning to part-time work
attending family events or recreational activities
Assess and follow function, pain severity, and quality of life using tools such as the three-item PEG (Pain average, interference with Enjoyment of life, and interference with General activity) assessment scale.
Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function.
Periodic reassessment is required to ensure that opioids are helping to meet patient goals and, if opioids are not effective or are harmful, to allow opportunities for consideration of opioid tapering and dosage reduction or discontinuation and of additional nonpharmacologic or nonopioid pharmacologic treatment options.
Opioid minimization and harm reduction:
prescribe the lowest effective dose
this can be determined using the prescribing information product labeling as a starting point with calibration as needed based on severity of pain and other clinical factors such as renal or hepatic insufficiency
If opioids are continued for subacute or chronic pain, use caution when prescribing opioids at any dosage and avoid dosage increases when possible
If a decision is made to increase dosage, use caution and increase by the smallest practical amount
Advise patients that there is an increased risk for overdose on abrupt return to a previously prescribed higher dose owing to loss of opioid tolerance
Evaluate the benefits and risks with patients within 1-4 weeks of starting opioid therapy for subacute (or chronic pain) or of dosage escalation.
For patients with chronic pain:
Regularly reevaluate the benefits and risks of continued opioid therapy with patients. It is recommended that patients receiving long-term opioid therapy are assessed at least every 3 months, including ongoing review of PDMP data.
For patients with chronic pain and risk factors for opioid use disorder or overdose (e.g., those with depression or other mental health conditions, a history of substance use disorder, a history of overdose, taking ≥50 MME in 24 hours, or taking other central nervous system depressants with opioids), evaluation more frequently than every 3 months is recommended.
Adult; with a history of or with current substance use disorder; with acute, subacute or chronic pain
All
Intervention
Individualized pain management approach; patient education for opioid risk mitigation; consider offering naloxone
If considering opioid therapy for a person with substance use disorder, discuss increased risks for opioid use disorder and overdose with patients, carefully consider whether benefits of opioids outweigh increased risks, and incorporate strategies to mitigate risk into the management plan, such as offering naloxone (see below).
Ensure that patients are provided or receive effective treatment for substance use disorders when needed. Communicate with patients’ substance use disorder treatment providers if opioids are prescribed.
It is recommended that clinicians use PDMP data and toxicology screening as appropriate to assess for concurrent substance use that might place patients at higher risk for opioid use disorder and overdose.
Consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants. Use particular caution when prescribing opioids concurrently to a patient already receiving benzodiazepines, understanding that this may be warranted in certain select clinical circumstances. Communicate with others managing the patient to weigh up the risks and benefits of concurrent treatment.
When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
Always use caution when considering or prescribing opioids for people with a history of substance use disorder; it is important not to overestimate the ability of available risk stratification tools to rule out risks of long-term opioid therapy. If using these tools, ensure that this is supplemental to other assessments, such as discussions with patients, family, and caregivers; clinical records; state PDMP data and toxicology screening data.
Management of pain in those with opioid use disorder is beyond scope of this table. Ensure that patients with opioid use disorder receive treatment with an evidence-based medication for opioid use disorder; detoxification alone (without concurrent medical treatment) is not recommended because of increased risks for resuming drug use, overdose, and overdose death. See Opioid use disorder.
Patient education for opioid risk minimization:
Offer specific counselling on increased risk for overdose when opioids are combined with other drugs or alcohol.
Educate patients prescribed opioids on overdose prevention and naloxone use and offer to provide education to members of their households.
Discuss increased risks including opioid use disorder at higher dosages, along with the importance of taking only the amount of opioids prescribed (i.e., not taking more opioids than prescribed or taking them more often).
Advise patients that there is an increased risk for overdose on abrupt return to a previously prescribed higher dose owing to loss of opioid tolerance.
Consider offering naloxone:
Offer naloxone when prescribing opioids, particularly to patients at increased risk for overdose, including those:
With a history of overdose
With a history of substance use disorder
With sleep-disordered breathing (but note that it is recommended that clinicians avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing when possible to minimize risk for respiratory depression)
Taking higher doses of opioids (e.g., ≥50 morphine milligram equivalents [MME] daily)
Taking benzodiazepines concurrently with opioids
At risk for returning to a high dose to which they have lost tolerance
Resources for prescribing naloxone in primary care and emergency department settings can be found through Prescribe to Prevent. PrescribeToPrevent: Prescribe Naloxone Save a Life Opens in new window
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of opioid use disorder and opioid overdose
Pregnant adult; with acute, subacute or chronic pain
Excludes people with pain related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
All
Intervention
Individualized pain management approach with shared decision-making
Pregnancy represents a special situation regarding opioid use for pain. It is recommended that a cautious approach to prescribing opioids is balanced with the need to address pain, and that pregnancy should not be a reason to avoid treating pain.
When making decisions about whether to initiate opioid therapy for pain during pregnancy, clinicians and patients together should carefully weigh benefits and risks.
Opioid use during pregnancy might be associated with risks to both the pregnant person and the fetus.
For pregnant women with chronic pain, strategies to avoid or minimize the use of opioids for pain management, include alternative pain therapies such as nonpharmacologic (e.g., exercise, physical therapy, and behavioral approaches), and nonopioid pharmacologic treatments. Some nonopioid pharmacologic treatments may not be recommended in pregnant women; consult your local drug information source for more information before prescribing.
Pharmacokinetic and physiologic changes occur during pregnancy, especially in the third trimester, and these changes might require dose adjustments.
For pregnant women already receiving opioids, it is important to access appropriate expertise if considering tapering opioids, because of possible risk to the pregnant patient and the fetus if the patient goes into withdrawal.
Goal
Maximization of pain and function outcomes; opioid minimization; prevention of maternal and fetal harm; prevention of opioid use disorder and opioid overdose
Secondary prevention
Unsterile injecting practices and risky sexual behavior among opioid users is a major contributor to the spread of HIV, hepatitis, and other infections.[196][197][198][199]
The Centers for Disease Control and Prevention (CDC) recommends hepatitis A vaccination for injection and noninjection drug users (i.e., all those who use illicit drugs).[182] The CDC also recommends universal hepatitis B vaccination in all adults ages 19 to 59 years.[182] 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.[182]
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).[181]
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 counseling 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.[111] 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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