What are the guidelines for chronic opioid therapy refills?

Guidelines for Chronic Opioid Therapy Refills

Chronic opioid therapy refills should follow a structured monitoring protocol with regular reassessment every 3 months or more frequently, including evaluation of benefits and harms, prescription drug monitoring program checks, and urine drug testing to ensure appropriate use and minimize risks. 1

Core Principles for Opioid Refills

• Before initiating chronic opioid therapy, establish clear treatment goals for both pain relief and functional improvement, and discuss how therapy will be discontinued if benefits do not outweigh risks 1
• Prescribe the lowest effective dosage, using caution at any dose and carefully reassessing when considering doses ≥50 morphine milligram equivalents (MME) per day 1
• Avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate to this level 1
• Evaluate benefits and harms within 1-4 weeks of starting opioid therapy or dose escalation, then every 3 months or more frequently 1

Required Monitoring for Refills

• Review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data before each refill 1
• Conduct urine drug testing before initiating opioid therapy and periodically during treatment to monitor adherence 1, 2
• Document comprehensive reassessment of pain, function, and quality of life using validated tools such as the PEG scale (Pain, Enjoyment, General activity) 1
• Monitor for signs of opioid use disorder, including difficulty controlling use and work/family problems related to opioid use 1
• Assess for adverse effects including constipation, sedation, and respiratory depression 1

Risk Mitigation Strategies

• Consider offering naloxone when risk factors for overdose are present (history of overdose, substance use disorder, doses ≥50 MME/day, or concurrent benzodiazepine use) 1
• Use a robust opioid therapy agreement that outlines expectations and responsibilities for both provider and patient 2
• Avoid concurrent prescribing of opioids and benzodiazepines whenever possible 1
• Store opioids in a secure, preferably locked location and discuss options for safe disposal of unused medications 1

Special Considerations for High-Risk Medications

• Use particular caution with methadone due to its unique risk profile and complex pharmacokinetics; it should not be the first choice for an extended-release/long-acting opioid 1, 3
• Exercise special care with fentanyl, as its dosing effects are often misunderstood and its absorption can be affected by heat and other factors 1
• When using methadone, consider baseline ECG and follow-up ECGs based on dose and risk factors to monitor for QTc prolongation 3

Tapering and Discontinuation

• Do not abruptly discontinue opioids in physically dependent patients as this can result in serious withdrawal symptoms, uncontrolled pain, and suicide risk 4
• When tapering is necessary, reduce by 10-25% of the total daily dose every 2-4 weeks 4, 5
• Reassess patients frequently during tapering to manage pain and withdrawal symptoms 4
• If withdrawal symptoms emerge, consider pausing the taper temporarily or slowing the rate of taper 4, 5
• Ensure a multimodal approach to pain management is in place before initiating an opioid taper 4, 5

Common Pitfalls to Avoid

• Failing to check PDMP data before refills, which can miss doctor shopping or dangerous drug combinations 1
• Neglecting to perform urine drug testing, which is essential for identifying non-adherence or illicit drug use 2
• Automatically refilling prescriptions without reassessing benefits and risks 1
• Inadequate documentation of functional improvement, which is critical for justifying continued therapy 1
• Not addressing constipation proactively with prophylactic bowel regimens 3, 2

By following these guidelines for chronic opioid refills, clinicians can help ensure appropriate pain management while minimizing risks associated with long-term opioid therapy.