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Safe Opioid Prescribing

Prescription pad and pen

Opioid equivalency is an imperfect science due to variability in the chemical properties of analgesic drugs and each particular patient's response to those drugs. Equivalent doses of opioid analgesics are frequently calculated with respect to oral morphine equivalents. In addition to offering guidelines on the safe use of opioids, the Washington State Agency Medical Directors Group provides a useful table (adapted below) as well as an online calculator for calculating morphine equivalent dosage (MED). Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 mg MEDs and should avoid increasing dosage to greater than or equal to 90 mg MEDs or carefully justify a decision to titrate dosage to ≥90 MME/day. When treating patients that exceed these thresholds providers should clearly document risk vs benefit, improvement in patient functional status, and applicable monitoring parameters.

Safe Opioid Prescribing:

  • Relies on the knowledge and skills of clinicians about the risks and benefits of opioid therapy
    • Risks: addiction, abuse, and diversion
    • Benefits: comfort, function, and quality of life
  • Complies with state and federal statutes
  • Fulfills responsibilities to patients, communities, and licensing authorities
Opioid Approximate Equianalgesic Dose (oral & transdermal)
Morphine (reference) 30mg
Codeine 200mg
Fentanyl transdermal 12.5mcg/hr
Hydrocodone 30mg
Hydromorphone 7.5mg
Oxycodone 20mg
Oxymorphone 10mg

Due to the unique properties of methadone, conversion between it and other opioids is particularly challenging. It is recommended that prescription of methadone be reserved for prescribers who specialize in pain management and/or are familiar with methadone. Many dosing tables may underestimate the potency of methadone. The analgesic effects of methadone are much greater with repeated dosing compared to one-time administration. The Department of Veterans Affairs and Department of Defense offer useful guidelines on the dosing of methadone.

When converting between opioids, prescribers and patients should be aware of the likelihood of incomplete cross tolerance. This term describes the phenomenon by which a patient's tolerance to one opioid agent may be markedly different from another agent, even at equianalgesic doses. Consequently, patients may be at increased risk for side effects and/or overdose when converting from one agent to another. It is generally recommended that prescribers account for incomplete cross tolerance when switching agents. This may be accomplished by scheduling the new agent at a dose 25-50% lower than the calculated equianalgesic dose with optional rescue doses provided in the event of uncontrolled or breakthrough pain.

Principles of Safe Opioid Prescribing

(based on the Federation of State Medical Board’s Model Policy for the Use of Controlled Substances for the Treatment of Pain [PDF - 44 KB])

  • Comprehensive evaluation and risk assessment of the patient
  • Informed consent and treatment agreement
  • Ongoing treatment review and patient monitoring
  • Individualized treatment and patient management plan
  • Maintaining transparent medical record
  • Specialized consultations
  • Adherence to controlled substances laws and regulations

CDC Guidelines Mobile App

The Centers for Disease Control and Prevention (CDC) recently launched a new mobile app for health care providers. This application is designed to help providers apply the recommendations of CDC’s Guideline for Prescribing Opioids for Chronic Pain into clinical practice by putting the entire guideline, tools and resources in the palm of their hand.

The CDC Opioid Guideline Mobile App Exit Disclaimer: You Are Leaving www.ihs.gov , available via free download, includes a Morphine Milligram Equivalent (MME) calculator, summaries of key recommendations, a link to the full guideline and an interactive motivational interviewing feature to help providers practice effective communication skills and prescribe with confidence.

Opioid Therapy Exit Strategies

Many clinical situations may warrant discontinuation of chronic opioid therapy (COT) and will require multi-disciplinary team (medical, pharmacy, behavioral health) approaches to accomplish. Patients who have been prescribed chronic opioid therapy will undergo a very unpleasant withdrawal syndrome if the medication is abruptly discontinued without an appropriate taper due to the psychological and physiological pharmacokinetic properties. When this occurs patients will often attempt to purchase opiates illicitly if unable to obtain from a pharmacy in order to avoid withdrawal sickness, creating an enormous health risk to the patient. It is recommended that a medication taper be employed when the decision to no longer prescribe opioids for chronic pain management, regardless of the reason for discontinuation. Following are common clinical scenarios along with recommended action plans.

Patient prescribed chronic opioid therapy (COT) AND…

  1. Urine Drug Screen is negative for the prescribed medication:
    1. Conduct a very thorough history to determine possible causes and rule out false negative lab result due to contamination or mishandling of specimen.
    2. Repeat a random Urine Drug Screen within a few days/weeks for confirmatory results
      1. If second UDS is negative for the prescribed opioid, then discontinue without taper. Withdrawal symptoms should not occur due to lack of opioid in urine and possible diversion.
  2. Urine Drug Screen is positive for prescribed chronic opioid therapy AND Prescription Drug Monitoring Program (PDMP) reveals violations of the controlled substance agreement (i.e. doctor shopping and multiple controlled substances from multiple pharmacies, etc.)
    1. Discuss the results with the patient
    2. Provider discretion to continue the chronic opioid therapy medication along with a referral to alcohol and other drugs of abuse counselor for dependence treatment. OR
    3. Discontinue the chronic medication therapy (COT) over a rapid taper
      1. Rapid taper will depend on the pharmacokinetic properties of the opioid
      2. General rule is dose decreases of no more than 10-25% every 3 to 5 days in order to reduce withdrawal symptoms; prescribe quantity sufficient for the entire taper with detailed directions to be placed on prescription label. Avoid verbal orders to the patient with taper instructions.
      3. Short acting opioids can be tapered more rapidly and for a shorter duration of time than long acting opioids (see below chart).
    4. Discuss the non-opioid medication therapy options, psychotherapy for chronic pain management, and other non-pharmacological adjunctive therapies. Reinforce that these strategies can be more effective than the chronic opioid therapy (COT) due to the opiate induced hyperalgesia effects from prolonged exposure.
  3. Urine Drug Screen is positive for prescribed medication AND also Non-prescribed controlled substances (i.e. violation of the controlled substance agreement) or Aberrant Behaviors
    1. Discuss the results with the patient
    2. Provider discretion to continue the chronic opioid therapy medication along with a referral to alcohol and other drugs of abuse counselor for dependence treatment. OR
    3. Discontinue the chronic medication therapy (COT) over a rapid taper
      1. Rapid taper will depend on the pharmacokinetic properties of the opioid
      2. General rule is dose decreases of no more than 10-25% every 3 to 5 days in order to reduce withdrawal symptoms; prescribe quantity sufficient for the entire taper with detailed directions to be placed on prescription label. Avoid verbal orders to the patient with taper instructions.
      3. Short acting opioids can be tapered more rapidly and for a shorter duration of time than long acting opioids (see below chart)
    4. Discuss the non-opioid medication therapy options, psychotherapy for chronic pain management, and other non-pharmacological adjunctive therapies. Reinforce that these strategies can be more effective than the chronic opioid therapy (COT) due to the opiate induced hyperalgesia effects from prolonged exposure.
Drug Half-Life (T ½)
(approximate)
Estimated Clearance
(5 half-lives)
*Hydrocodone
(Vicodin, Norco)
~8 hours ~40 hours
*Oxycodone IR
(Percocet, oxycodone)
~2-4 hours ~10-20 hours
*Oxycodone ER
(Oxycontin)
~5 hours ~10 hours
*Morphine
(IR, MS Contin)
IR: ~ 2-4 hours
ER: ~ 11-13 hours
IR: ~10-40 hours
ER: ~55-65 hours
*Methadone ~8-59 hours ~40-295 hours/(2-13 days)
*Bupenorphine
(Suboxone/Subutex)
~37 hours ~185 hours/(8 days)

* Information adapted from UpToDate/Lexicomp®

Consult your pharmacist team to determine a reasonable taper strategy based on the prescribed dose of the specific opioid agent as well as a referral to behavioral health for psychological support and counseling during the taper. Consider transitioning to a chronic pain management treatment strategy that does not include chronic opioid therapy.

References

WA State Agency Medical Directors Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy, 2010 Update Exit Disclaimer: You Are Leaving www.ihs.gov .

Department of Veterans Affairs/Department of Defense. Clinical practice guideline for management of opioid therapy for chronic pain. Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF]

Webster LR, Fine PG. Overdose Deaths Demand a New Paradigm for Opioid Rotation. Pain Medicine. 2012; 13: 571-574

PL Detail-Document, Opioid Conversion Algorithm. Pharmacist's Letter/Prescriber's Letter. August 2012.