Primary prevention

Before starting any opioid therapy, efforts should be made to maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate. There is evidence that shows nonopioid therapies are at least as effective as opioid therapies for acute pain, and that they are preferred to opioid therapies for subacute and chronic pain.[12][13] This may have potential implications for further reducing the use of opioids in the emergency department and in the community. Opioid therapy should only be considered if expected benefits for pain and function are anticipated to outweigh risks to the patient.[13]

Clinicians prescribing opioids should identify treatment resources for opioid use disorder in the community, and establish a network of referral options across the different levels of care that patients might need. This is to ensure prompt referral and treatment, if needed.[13]

Prescribers should be alert to the increasing problem of prescription opioid use disorder and prescribe opioids judiciously for chronic pain.[13]​ The patient’s history of controlled substance prescriptions should be reviewed ideally before every opioid prescription, and at the very least, prior to the first prescription and then at 3-monthly intervals. This can help determine whether the patient is receiving opioid dosages from multiple prescribers, which puts them at increased risk of overdose. In the US, patient prescribing histories can be viewed via state Prescription Drug Monitoring Programs (PDMPs).[14]​ Using PDMPs to inform treatment decisions has changed prescribing behaviors and decreased opioid-related harms and treatment admissions.[15]​ However, PDMP-generated risk scores have not been validated against clinical outcomes such as overdose, and therefore should not take the place of clinical judgment.[13]

Patients who regularly use opioids (therapeutically or recreationally) should be educated about the dangers of overdose, especially after periods of abstinence. This education is associated with a reduction in death from overdose.[16] Patients at high risk, together with family members and caregivers, should be educated about the recognition and management of opioid overdose, including the administration of naloxone.[8][13]​​[14][17]

​The US Department of Health and Human Services (HSS) and Centers for Disease Control and Prevention (CDC) advise clinicians to strongly consider co-prescribing naloxone alongside opioids for the following groups:[13][18]​​

  • Those receiving opioids at high doses (50 milligram morphine equivalents dose per day, or greater)

  • Patients with sleep-associated respiratory conditions such as sleep apnea

  • Those prescribed benzodiazepines

  • Patients with a history of alcohol or nonopioid substance use disorder

  • Those at risk for returning to a high dose to which they have lost tolerance (e.g., patients undergoing tapering or those recently released from prison).

The HHS further recommends prescribing naloxone for patients who have a mental health disorder, and also for those who use heroin or illicit synthetic opioids, who misuse prescribed opioids, and/or who use other illicit drugs, which may be contaminated by synthetic opioids (such as fentanyl).[14]​ In the US, naloxone may be co-prescribed to be administered intramuscularly, intravenously, and subcutaneously.[14]​​

In some countries (e.g., England) naloxone has long been available without a prescription and can be obtained by a family member or friend of a heroin user at risk, for the purpose of saving life in an emergency.[19] In the US, naloxone nasal spray is approved for use without a prescription. 

Note that available naloxone may be insufficient to reverse an overdose; patients, family members, and caregivers should be advised to call emergency services immediately upon recognition of an opioid overdose.[8] 

Co-prescription of opioids and benzodiazepines should be avoided whenever possible as their concurrent use increases the risk of potentially fatal overdose.[13][20][21]

Extreme caution should be exercised when prescribing and using fentanyl patches due to the increased risk of serious and fatal overdose.[22] Reports of overdose are related to dosing errors, accidental exposure, and exposure of a patch to a heat source (including increased body temperature resulting from a fever). Children are particularly at risk of accidental exposure (e.g., a partially detached patch may be transferred from an adult to a child during sleep or a child may think the patches are stickers or tattoos).[23] Patients and caregivers should therefore be provided clear follow guidance on how to store, use, and dispose of patches safely.

If clinicians suspect opioid use disorder, they should assess for this using DSM-5-TR criteria.[24] Clinicians should discuss their concerns with their patients in a nonjudgmental manner, and allow the patient to disclose any related issues. Opioid use disorder can coexist with other substance use disorders; therefore, clinicians should ask about use of alcohol and other substances.[13]

Evidence-based medication should be arranged for those with opioid use disorder; this has been associated with reduced risk for overdose and overall deaths. Detoxification alone, without medications for opioid use disorder, is not recommended due to increased risks of resuming drug use, overdose, and overdose-related deaths.[13] Medication-assisted treatment (the use of medications in combination with counseling and behavioral therapies) may prevent opioid overdose in people with opioid use disorder.[8]

If clinicians are unable to provide medication themselves, it should be arranged for patients to receive care from another appropriate source. In the US, this may be a substance use disorder specialist or from a Substance Abuse and Mental Health Services Administration certified opioid treatment program.[13]

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