the method for obtaining naloxone from community naloxone programs or pharmacies, where available
Keep the dose below 50 mg MED. Most patients respond well to doses of 50 mg MED or less. For patients receiving opioid doses above 90-120 mg MED, strongly consider requesting a second opinion from another healthcare provider, and advise these patients to get a naloxone kit from the pharmacy, where available. The risk of overdose and the inherent risk of addiction increase steeply at higher doses.
Tapering Opioids
Taper the opioid dose when necessary. Taper the dose in the following situations:
patient has experienced no improvement in function with opioid therapy
patient is experiencing opioid-induced sedation, depression, fatigue, sleep disturbance, or other harm
there is a concern that the patient is experiencing opioidinduced hyperalgesia
there is a concern that the patient may have an opioid use disorder
Consider tapering for any patients who are receiving doses above 50 MED, particularly those whose doses are over 200 MED. Many patients on higher doses will actually experience improvements in their pain, mood, and function when their dose is lowered. Taper doses by no more than 10 % of the total daily dose every 1-4 weeks. Whenever possible, use scheduled rather than as needed( PRN) doses. Dispense small quantities frequently( as often as daily), depending on the patient’ s adherence to the tapering schedule.
For patients who are taking high doses, do not stop the opioids suddenly. Abrupt cessation may cause patients who are taking high doses to go into severe withdrawal. This may lead them to seek other sources of opioids, which puts them at risk of overdose and other harms.
Opioid Use Disorder: Diagnosis and Management
Know how to diagnose opioid use disorder. The clinical features of opioid use disorder include requirement for higher doses than expected for an underlying pain condition, resistance to tapering despite poor analgesic response, alarming behaviours( e. g., patient frequently runs out early; patient accesses opioids from other sources; patient snorts, crushes, or injects oral opioids), poor psychosocial function and mood, and binge use with frequent withdrawal symptoms. If the diagnosis is unclear, prescribers should:
closely monitor the patient with frequent visits and urine drug screens( at least every 2 weeks)
dispense opioids frequently( 1-7 times weekly) in small quantities
closely monitor the patient’ s pain and function
refer patients to and / or seek a consult( by phone or email) with an addiction physician
If the patient has an opioid use disorder, develop and discuss the treatment plan with the patient. Include the following messaging in your discussion of the treatment plan:
options for initiation of buprenorphine or referral to an addiction specialist
Issue 4, 2016 Dialogue 29