change to their treatment plan, especially
opioid tapering or switching. These behaviours are driven by the patient’s addiction
and attempts to avoid opioid withdrawal.
Concerned, some physicians act hastily and
abruptly stop prescribing or even terminate
the physician-patient relationship. This is
not appropriate.
Sometimes physicians may wish to stop
prescribing opioids even if opioid use disorder is not suspected. This could be for a
variety of reasons; for example, the patient
has poor pain control despite a high dose,
or the physician has decided to stop opioid prescribing altogether due to fears of
regulatory scrutiny or because of clinic or
institution policies.
Finally, when patients on opioid substitution treatment (e.g., methadone or buprenorphine) are admitted to a hospital or a
corrections facility, some physicians discontinue the opioid substitution treatment due
to lack of knowledge, logistical issues, or
other concerns.
What are the associated risks to
patients?
Sudden discontinuation of opioids puts
patients at high risk of overdose in two
main ways. First, patients experiencing opioid withdrawal may seek other sources of
opioids and overdose by using opioids that
have not been prescribed to them. This is
especially a concern with the current availability of street sources of highly potent
fentanyl analogues. Second, patients lose
opioid tolerance within a short period of
time after discontinuing opioids, and may
overdose if they resume opioids at previous
doses.
Sudden cessation of methadone or buprenorphine in a hospitalized patient puts
them at risk for various cardio-respiratory
complications triggered by withdrawal. For
example, a methadone patient admitted to
hospital with COPD exacerbation could
suffer respiratory failure if the methadone is
suddenly discontinued.
Resources
Opioid tapering protocol
• Opioid tapering - when reducing or discontinuing an
opioid in chronic non‐cancer pain. July, 2014.
• Canadian guideline for safe and effective use of opioids for
chronic non-cancer pain. Appendix B-12: opioid tapering.
McMaster University, 2010.
Education on overdose prevention
• Preventing opioid overdose. Centre for Addiction and
Mental Health.
16
Dialogue Issue 3, 2016
Overdose response
•P
OINT: Prevent Overdose In Toronto. Toronto Public
Health, 2016.
Diagnosing opioid use disorder and prescribing
buprenorphine
•B
uprenorphine-assisted treatment of opioid dependence:
an online course for front-line clinicians. Centre for Addiction and Mental Health, 2012.
•B
uprenorphine/naloxone for opioid dependence: clinical practice guideline. Centre for Addiction and Mental
Health, 2011.