What strategies can primary care physicians use to reduce diversion and opioid-induced harm?

Strategies to Reduce Diversion and Opioid-Induced Harm in Primary Care

Primary care physicians should limit acute pain opioid prescriptions to ≤3 days at the lowest effective dose of immediate-release formulations, implement prescription drug monitoring programs (PDMPs) and treatment agreements, and educate patients on safe storage and disposal to prevent diversion. 1

Prescribing Strategies to Minimize Diversion Risk

Limit Initial Opioid Exposure

• Prescribe ≤3 days of immediate-release opioids for acute pain conditions, as this duration is sufficient for most non-surgical, non-trauma acute pain in primary care settings 1
• Prescriptions exceeding 7 days are rarely needed and significantly increase physical dependence risk and pill availability for diversion 1
• Each additional day of unnecessary opioid exposure increases likelihood of physical dependence without adding therapeutic benefit 1
• Use the lowest effective dose based on product labeling, adjusted for pain severity and patient factors like renal or hepatic insufficiency 1
• Data show that among patients receiving an initial 7-day supply, <25% required refills for nine of 10 acute pain conditions 2

Avoid Extended-Release Formulations

• Prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) formulations when initiating opioid therapy 1
• Extended-release formulations carry higher diversion and abuse potential 1

Maximize Non-Opioid Alternatives First

• Prioritize acetaminophen and NSAIDs as first-line agents for mild-to-moderate acute pain before considering opioids 3
• Implement multimodal analgesia combining nonpharmacologic therapies (physical therapy, acupuncture, massage) with nonopioid medications 1, 4
• Reserve opioids only for severe pain unresponsive to other modalities 1

Monitoring and Documentation Systems

Prescription Drug Monitoring Programs (PDMPs)

• Participate fully in state PDMPs to identify doctor shopping and prevent multiple prescriptions from different providers 1
• PDMPs are statewide electronic databases that track controlled substance prescriptions and help detect suspected abuse or diversion patterns 1
• Check PDMP data before prescribing opioids and periodically during ongoing therapy 1

Treatment Agreements (Opioid Contracts)

• Establish formal written agreements with patients receiving opioids that define:
  • Potential risks and benefits of opioid therapy 1
  • Prescribing policies including single provider/pharmacy requirements 1
  • Methods for monitoring opioid use (urine drug screening) 5
  • Expected patient behaviors and responsibilities 1
  • Consequences of contract violations including treatment discontinuation 1
• These contracts document informed consent, reduce clinician legal risk, and allow physicians to stop prescribing when treatment goals are not achieved 1

Regular Patient Assessment

• Evaluate patients at reasonable intervals (at least weekly during the first month, then monthly once stable) based on individual circumstances 5
• Assess for signs of medication misuse, diversion, or substance use disorder at each visit 1, 5
• Monitor for responsible medication handling and compliance with all treatment plan elements 5
• Verify abstinence from illicit drug use through urine drug screening 5

Risk Assessment and Mitigation

Pre-Prescribing Risk Evaluation

• Before starting opioid therapy, evaluate risk factors for opioid-related harms including:
  • History of overdose or substance use disorder 1
  • Concurrent benzodiazepine use 1
  • Mental health conditions (anxiety, depression) that may be unmasked by opioid therapy 1
• Consider offering naloxone when risk factors are present, particularly at doses ≥50 MME/day 1

Establish Clear Treatment Goals

• Set realistic goals for pain relief and functional improvement before initiating opioids 1
• Determine in advance how therapy will be discontinued if benefits do not outweigh risks 1
• Continue opioid therapy only when there is clinically meaningful improvement in pain and function 1
• Re-evaluate benefits and harms within 1-4 weeks of starting therapy and every 3 months thereafter 1

Patient Education on Diversion Prevention

Safe Storage and Disposal

• Advise all patients on proper storage of opioids to prevent access by family members or visitors 1
• Instruct patients on safe disposal methods for unused medications and emphasize never sharing prescriptions with others 1
• The most common form of diversion is transfer from prescribed patients to family or friends for self-medication of generic pain 1
• Educate patients that sharing medications creates serious risks including overdose and death in opioid-naïve individuals 1

Avoid "Just in Case" Prescribing

• Do not prescribe additional opioids beyond the expected pain duration "just in case" pain continues 1
• Excess pills increase availability for unintentional or intentional diversion 1
• Patients can contact the provider if pain persists beyond the prescribed duration rather than having excess medication at home 1

Referral and Consultation Strategies

When to Refer for Substance Use Disorder Evaluation

• Refer patients for substance abuse consultation when there are questions or concerns about medication misuse or diversion 1
• Specialists can assist with establishing treatment agreements, limit setting, and single provider/pharmacy arrangements 1
• Patients who continue to misuse, abuse, or divert opioids should be provided with or referred to more intensive and structured treatment 5

Discontinuing Inappropriate Patients

• Recognize when you cannot appropriately manage particular patients who are abusing multiple substances or unresponsive to psychosocial intervention 5
• Refer to specialists or more intensive behavioral treatment environments based on the treatment plan established at the beginning of therapy 5
• Treatment agreements allow for discontinuation when patients violate terms, protecting both patient safety and reducing diversion risk 1

Common Pitfalls to Avoid

• Avoid prescribing multiple refills early in treatment without appropriate patient follow-up visits 5
• Do not rely solely on unidimensional pain scores to guide prescribing and titration, as this approach contributed to overprescribing 1
• Avoid prescribing opioids without concurrent implementation of monitoring strategies (PDMPs, treatment agreements, regular assessments) 1
• Do not assume all patients require the same duration of therapy—while ≤3 days is sufficient for most, some conditions may require up to 7 days based on clinical judgment 1