The most conservative addiction and overdose prevention policies and procedures can’t protect a primary care clinician from inheriting a patient who is taking high doses of opioids for chronic pain. In many cases, because of the patient’s limited resources or the limited number of specialists in the community, primary care clinicians are expected to satisfy the patient’s needs for specialty care, including pain management, mental health, and physical therapy. Although there is no perfect solution for clinicians faced with these challenging patients, the following recommendations can decrease the risk of overdose and increase the chance that patients can be transitioned to safer pain management:*
- Review the benefits and risks of continued high-dosage opioid therapy with the patient.
- Determine whether the patient is achieving any pain or function improvement on current doses.
- Offer to collaborate with the patient to taper medications to safer dosages or discontinue opioids.
- Do not rush the tapering schedule. Patients who have been taking opioids for many years may require very slow tapers with occasional pauses.
- Identify and treat anxiety, depression, and opioid use disorder that may arise during tapering/discontinuing.
- Consult with mental health or addiction specialists.
- Maximize nonpharmacologic and nonopioid pharmacologic treatments as appropriate.
- Consult with a pain management specialist.
- Have an opioid prescribing discontinuation plan in place that utilizes pain management policies and protocols for patients attempting tapering or discontinuing long-term opioid therapy.
- Consider using a medication termination agreement (e.g., see “Universal Precautions Revisited: Managing the Inherited Pain Patient, Appendix 1: Termination of Controlled-Substances Agreement”).
Resources for Counseling and Managing Inherited Patients on High Doses of Opioids
Although limited, there are resources for counseling and managing inherited chronic pain patients who are taking high doses of opioid pain medications, including:
- Boston University’s online opioid prescribing course, “Safe and Effective Opioid Prescribing for Chronic Pain.”
- Module 5, Case 1-A, of the video case studies provides materials addressing high-dose opioids in an inherited patient.
- Gourlay DL, Heit HA. “Universal Precautions Revisited: Managing the Inherited Pain Patient.” Pain Medicine 2009 Jul; 10 (suppl 2): S115-S123.
Resources for Tapering and Discontinuing Opioid Pain Medications
Opioid tapering and discontinuation should be individualized. The following resources may provide some guidance in constructing tapering/discontinuation policies and procedures for long-term opioid users:
- U.S. Department of Veterans Affairs “Opioid Taper Decision Tool” (PDF)
- Washington State Health Care Authority “Tapering Plan for Patient with Chronic, Non-Cancer Pain” (file download)
- McMaster University National Pain Centre “Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, Appendix B-12: Opioid Tapering”
Reference
* Deborah Dowell, et. al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports 2022;71(No. RR-3):1–95. November 4, 2022. DOI: 10.15585/mmwr.rr7103a1
