Prescribe opioids with caution for patients at high risk of addiction . There are two major risk factors for opioid addiction :
current or past history of alcohol or substance use disorder
current or past history of a psychiatric disorder ( including anxiety , depression , and post-traumatic stress disorder )
Do not prescribe potent opioids for high-risk patients unless they have a pain condition that interferes with daily life and has not responded to a full trial of all major pain treatments ( e . g ., nonsteroidal antiinflammatory agents , antidepressants , anticonvulsants , physiotherapy and other nonpharmacologic therapies ). In cases where opioids are to be prescribed for high-risk patients , avoid hydromorphone , fentanyl , and oxycodone ; dispense small quantities at frequent intervals ( rather than larger amounts at extended intervals ); order regular urine drug screens to identify use of nonprescribed opioids , benzodiazepines , or other drugs ; and educate patients and families about overdose and harm prevention .
Opioid Selection and Dosage
Treat all opioid prescribing as a therapeutic trial . There have been no long-term (> 1 year ) controlled trials of the effectiveness of opioids , and cohort studies have indicated that patients receiving long-term opioid therapy have worse pain and function outcomes than patients with similar pain conditions who are not taking opioids . Therefore , the opioid should be tapered and discontinued if it does not significantly improve pain and function at a dose of 50 mg MED 1 or if the patient experiences fatigue , sedation , or other side effects .
Start with weak opioids first . Weak opioids include codeine , tramadol products , and transdermal buprenorphine . Switch to a potent opioid only if the weak opioid is ineffective . If a potent opioid is needed , use low doses of a short-acting formulation for initial titration . Avoid fentanyl . Do not prescribe benzodiazepines concurrently with opioids .
Recommend the lowest possible dose for the shortest possible time . Low doses and slow dose titration are appropriate for all patients , but are especially important for those at risk for opioid-induced falls , sedation , and other harms . Risk factors for opioid-induced falls , sedation , and other harms include advanced age , concomitant benzodiazepine or other sedating medications , alcohol use , sleep apnea , and impairment of renal , hepatic , or respiratory function . Do not prescribe opioids for nighttime use by elderly patients who are at high risk for falls .
Advise patients about opioid-related harms and prevention of overdose . Use patient-specific handouts , such as Opioid Pain Medicines – Information for Patients and Families , to support discussion of the following issues of concern :
impairment of ability to drive or operate machinery , especially after initiation of an opioid or after an increase in dose
avoidance of the combination of opioids with alcohol , benzodiazepines , or illicit drugs
the need to alert family members and friends to the initiation of opioid treatment , as well as the symptoms and signs of opioid toxicity
the requirement for secure storage of opioids , especially if children or young adults live in the same house as the patient
the requirement to not share opioids with others or take opioids from others
MED = morphine equivalents / day , also known as morphine milligram equivalents ( MME )/ day . This is the total amount of opioid consumed in a 24-hour period , converted to the morphine-equivalent daily dose in milligrams . Potency ratios : morphine = 1 , oxycodone = 1.5 , hydromorphone = 5 ( available from http :// nationalpaincentre . mcmaster . ca / opioid / cgop _ b _ app _ b08 . html ). 1
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Dialogue Issue 4 , 2016