anticipated benefits of the treatment plan, including reduction of pain, prevention of overdose, and improvement in mood, energy level, and function never use opioids alone and avoid taking benzodiazepines or alcohol at the same time as an opioid. If available, use opioids at a safe injection site.
For most patients with opioid use disorder, initiate buprenorphine or refer the patient to an addiction physician for buprenorphine or methadone treatment. Both buprenorphine and methadone have been shown to dramatically reduce opioid use, crime, and overdose. Buprenorphine can be safely prescribed and managed by family physicians. If the patient refuses the treatment plan, and will not attend an addiction clinic, then taper the dose over 1-3 months, with frequent dispensing( as often as daily). Continue to offer primary care, unless the patient has been abusive to office staff or other patients.
Educate patients with opioid use disorder about overdose and harm prevention. All patients on opioids should be educated about overdose and harm prevention, in particular those with opioid use disorder. Several key points should be addressed:
For all patients taking illicit opioids or high doses of prescription opioids:
Obtain a take-home naloxone kit. In many regions of the country, these kits are available at no cost and without a prescription, through naloxone programs or pharmacies.
Avoid taking benzodiazepines or alcohol at the same time as the opioid.
Use a lower dose if the opioid has not been taken for several days or more. Patients on prescribed opioids should contact their doctor for guidance.
For patients who misuse opioids( e. g., inject, crush or snort opioids, or acquire opioids from non-medical sources):
Give naloxone if a friend may have overdosed on opioids and call 911. Never leave the friend alone to“ sleep it off”.
Use pharmaceutical opioids obtained by prescription rather than illicit opioids obtained from other sources. Caution patients that opioids obtained from other sources may contain fentanyl and that other dangerous adulterants are often added to heroin, morphine, oxycodone, and even to cocaine or crystal methamphetamine. This further increases the risk for overdose and death, even for heavy and experienced users.
Conclusion Opioid prescribing and management in the community are complex issues. This report summarizes key prescribing messages that aim to minimize the use of opioids and reverse their associated harm, as well as to support community prescribers in the treatment of opioid use disorder. MD
Acknowledgements ISMP Canada gratefully acknowledges members of the expert panel who shared their expertise for the expert panel meeting, as well as the following individuals for their expert review of this bulletin
Laurie Dunn MSc BScPhm, Six Nations Family Health Team and Medication Use Management Services, Toronto, ON; Meldon Kahan MD CCFP, Medical Director, Substance Use Service, Women’ s College Hospital, Toronto, ON; Pamela Leece MD MSc CCFP FRCPC, Clinical Associate, Substance Use Service, Women’ s College Hospital, Toronto, ON; John Pilla MSc BScPhm, Medication Use Management Services, Toronto, ON; and Sheryl Spithoff MD CCFP, Staff Physician, Women’ s College Hospital, Toronto, ON.
Reprinted with permission from ISMP Canada.
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Dialogue Issue 4, 2016