What interventions are immediately warranted when a patient prescribed opioids exhibits signs or symptoms of substance abuse?

Immediate Interventions for Patients on Opioids Showing Signs of Substance Abuse

When a patient prescribed opioids exhibits signs or symptoms of substance abuse, the most immediately warranted intervention is to assess for opioid overdose risk and provide naloxone while simultaneously initiating referral for medication-assisted treatment (MAT) with either buprenorphine or methadone. 1

Initial Assessment and Immediate Safety Measures

• Assess for life-threatening conditions first:

  • Check for respiratory depression, altered mental status, or signs of overdose
  • If overdose is suspected, administer naloxone immediately (2 mg intranasal or 0.4 mg intramuscular) 1
  • Activate emergency medical services for patients with respiratory depression or overdose

• Screen for severity of substance abuse:

  • Look for signs of opioid use disorder: craving, inability to control use, using larger amounts than prescribed, continued use despite harm 1
  • Assess for withdrawal symptoms: anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia 1
  • Check prescription drug monitoring program (PDMP) data immediately to identify multiple prescribers or dangerous combinations 1

Immediate Medication Interventions

For Patients at Risk of Overdose:

• Prescribe naloxone to the patient and educate family members on its use 1
  • Naloxone can reverse opioid overdose effects but may precipitate withdrawal symptoms in opioid-dependent individuals 2
  • Patients who respond to naloxone should still access advanced healthcare services 1

For Patients with Substance Abuse:

• Initiate medication-assisted treatment referral immediately:
  • Buprenorphine (partial opioid agonist) for suppressing withdrawal symptoms and reducing cravings 3, 4
  • Methadone (full opioid agonist) for patients with more severe opioid use disorder 5, 4
  • Naltrexone (opioid antagonist) as an alternative for patients who have been detoxified 4

Immediate Prescribing Changes

• Reassess current opioid regimen:

  • Consider tapering or discontinuing opioid prescriptions if safe to do so 1
  • For patients on long-term therapy, initiate a slow taper (10% per month) rather than abrupt discontinuation 1
  • Eliminate concurrent benzodiazepine prescriptions due to increased overdose risk 1
  • Document the substance abuse diagnosis and prescribing changes 6

• Maximize non-opioid pain management:

  • Prescribe non-opioid analgesics (NSAIDs, acetaminophen) for pain control 1, 7
  • Consider adjuvant medications like pregabalin or duloxetine for neuropathic pain 7
  • Initiate referrals for physical therapy and cognitive behavioral therapy 7

Immediate Referrals and Follow-up

• Arrange substance abuse treatment:

  • Refer to addiction specialist or opioid treatment program within 24-48 hours 1, 4
  • Consider emergency department referral for patients requiring immediate stabilization 1
  • Connect patient with behavioral health services for co-occurring mental health conditions 1, 7

• Establish close monitoring:

  • Schedule follow-up within 1 week to assess response to interventions 1
  • Implement urine drug testing to monitor for continued substance use 1
  • Continue to check PDMP with each prescription to identify potential diversion 1

Common Pitfalls to Avoid

1. Abrupt discontinuation of opioids can lead to severe withdrawal, mental health crises, and increased overdose risk if patients seek illicit opioids 1

2. Dismissing patients from practice after discovering substance abuse, which can worsen outcomes and miss opportunities for intervention 1

3. Focusing only on opioid discontinuation without addressing underlying substance use disorder with evidence-based treatments 4

4. Neglecting overdose prevention by failing to prescribe naloxone to at-risk patients and their families 1, 8

5. Overlooking mental health conditions that often co-occur with substance use disorders and may worsen during opioid tapering 1, 9

By implementing these immediate interventions when signs of substance abuse are identified, clinicians can reduce the risk of overdose death while initiating appropriate treatment for opioid use disorder, ultimately improving patient outcomes and quality of life.