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