As an Idaho provider, you play an important role in combating the opioid epidemic. Find resources and information to support and inform clinical decision-making.
In October 2020, it became required by law to review a patient’s prescription drug history for the preceding 12 months from the prescription drug monitoring program (PMP) and evaluate the data for evidence of prescription misuse or diversion when prescribing an opioid analgesic or benzodiazepine listed in schedules II, III, or IV. To comply with this requirement, providers are required to register and use the Idaho PDMP, the statewide electronic database that collects designated data on controlled substances dispensed in Idaho. The Idaho PDMP is connected with PDMPs in neighboring states, thereby allowing prescribers to review prescriptions filled from numerous other states throughout the nation.
Find more information about the program or to register for an account, visit Idaho PMP AWARE.
There are two FDA-approved opioid overdose reversal medications (OORMs), naloxone and nalmefene. These medications are opioid antagonists that rapidly reverse an opioid overdose, even in instances when opioids are used in combination with other sedatives or stimulants. OORMs are not effective in treating overdoses of benzodiazepines, stimulant overdoses involving cocaine and amphetamines, or the effects of xylazine, a highly sedating substance often found in fentanyl and other illicit substances.
When naloxone was first approved by the FDA, its brand name was “Narcan.” There are now other formulations and brand names for naloxone, but many people continue to call all of these products “Narcan.” However, the proper generic name is “naloxone.”
OORMs rapidly reverse respiratory depression caused by acute opioid intoxication or poisoning and quickly restore normal breathing, preventing death from an opioid overdose. Research shows that clinicians prescribing naloxone along with prescription opioids reduce the risk of opioid-related emergency room visits and prescription opioid-involved overdose deaths. The U.S. Centers for Disease Control and Prevention recommends providing a co-prescription of naloxone for patients who take opioids.
Find more information on SAMHSA’s web portal “Opioid Overdose Reversal Medications (OORM)” or at NIDA’s DrugFacts.
Guidelines for Prescribing Opioids
In 2022, the CDC released the “Clinical Practice Guideline for Prescribing Opioids for Pain” to enhance the safety and effectiveness of pain treatment while mitigating the risks associated with opioid therapy. Although not intended to replace clinical judgment, the guideline is meant to serve as a clinical tool for primary care practitioners when making decisions regarding opioid prescribing. The guideline comprises 12 recommendations including considerations for initiating opioids for pain, selecting appropriate opioids and determining dosages, deciding on the duration of initial prescriptions, conducting follow-ups, and assessing and addressing potential risks and harms associated with opioid use.
To access the full CDC Prescribing Guideline, please visit the CDC website.
Given its effectiveness and lower risk profile compared to full opioid agonists, numerous reputable institutions recommend considering buprenorphine as the choice of treatment for pain including initial pain management, treatment for those who have not adequately responded to non-opioid treatments, treatment for those with a history of or an active diagnosis of substance use or use disorder, or for those at an increased risk from the use of other opiates. This includes such institutions as the Centers for Disease Control and Prevention (CDC), the American Society of Addiction Medicine (ASAM), the Substance Abuse and Mental Health Services Administration (SAMHSA), the American Pain Society (APS) and the World Health Organization (WHO), which includes buprenorphine on its list of essential medicines for pain management.
In addition to the guidelines referenced above, review these guidelines and articles for more information regarding the use of buprenorphine for pain:
US Department of Veterans Affairs (VA) and the Department of Defense (DoD): “The Use of Opioids in the Management of Chronic Pain,” in the Annals of Internal Medicine, and the National Guidance Document issued.
“Buprenorphine for Chronic Pain: A Safer Alternative to Traditional Opioids,” from the National Institutes of Health in Health Psychology Research.
This Systematic Review from JAMA, “Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain,”
“Frontline Perspectives on Buprenorphine for the Management of Chronic Pain,” from the Journal of Interdisciplinary Healthcare
Calculating the total daily dose of opioids helps identify patients who are at higher risk of overdose.
Use extra precautions for patients at ≥50 MME/day. Consider closely monitoring patients, reducing or tapering of opioids, and/or prescribing of naloxone. Avoid or carefully justify increasing dosage to ≥90 MME/day.
Calculating MME
1. Determine the total daily amount of each opioid the patient takes
2. Convert each to MME — multiply the dose for each opioid by the conversion factor (see table)
3. Add them together
Select the link to access a free opioid dose calculator
Clinicians should carefully weigh both the benefits and risks of continuing opioid medications and the benefits and risks of tapering opioids. The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain does not support rapid dosage tapering, patient abandonment, or abrupt discontinuation of opioids.
General considerations for changing opioid dosages:
- If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy.
- When benefits (including avoiding risks of tapering) do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to a reduced opioid dosage or, if warranted based on the individual clinical circumstances of the patient, appropriately taper and discontinue opioid therapy.
For more guidance on tapering opioid prescriptions, refer to the Summary of the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain
(2023)
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