What are the guidelines for opioid (narcotic analgesics) refills?

Opioid Refill Guidelines

Opioid prescriptions should be limited to 5-7 days maximum at discharge, must never be added to repeat prescription templates, and require explicit documentation of dose and duration in discharge communications to prevent inadvertent conversion to chronic therapy. 1

Critical Refill Restrictions

Duration Limits

• Prescribe 5 days as standard, with an absolute maximum of 7 days for postoperative or acute pain 1
• Never prescribe opioids as repeat/refill prescriptions - they must only be documented as acute medications 1
• For chronic non-cancer pain, reassess every 3 months minimum before any continuation 1

Documentation Requirements for Any Opioid Prescription

• Explicitly state the recommended opioid dose, total amount supplied, and planned duration in all discharge letters and communications 1
• Provide discharge letters promptly to all healthcare professionals including community pharmacists to prevent acute prescriptions inadvertently becoming repeat prescriptions 1
• Document the opioid treatment plan with patient agreement 1

Prescribing Algorithm for Refills

Step 1: Assess Medical Necessity

• Confirm pain intensity ≥4/10 or functional impairment despite non-opioid therapy 2, 3
• Verify comprehensive assessment including physical diagnosis, imaging correlation, and psychological status 2, 3
• Rule out surgical complications (compartment syndrome, anastomotic leak) as cause of increased pain 1

Step 2: Risk Stratification Before Any Refill

• Check prescription drug monitoring program (PDMP) for patterns of doctor shopping or concurrent prescriptions 1, 2
• Perform urine drug testing (UDT) to identify non-adherence or illicit drug use 1, 2, 3
• Screen for absolute contraindications: active substance abuse, concurrent benzodiazepines, respiratory instability, uncontrolled psychiatric conditions 1, 3

Step 3: Determine if Refill is Appropriate

Refill is NOT appropriate if:

• Original prescription was for postoperative pain and patient is beyond 7 days post-discharge 1
• Patient shows aberrant drug-related behaviors on monitoring 1, 2
• Pain has not improved by ≥30% with current therapy 2
• PDMP shows concerning patterns 1, 2
• UDT reveals non-adherence or illicit substances 2, 3

Refill may be considered only if:

• Documented medical necessity with objective findings 2, 3
• Pain is from cancer or cancer treatment with ongoing need 1
• Chronic non-cancer pain with demonstrated ≥30% improvement in pain/function 2
• All monitoring (PDMP, UDT) shows appropriate use 1, 2

Step 4: Refill Specifications When Appropriate

• Use immediate-release formulations only - avoid long-acting or extended-release opioids without specialist consultation 1
• Start with lowest effective dose: consider up to 40 morphine milligram equivalents (MME) as low dose, 41-90 MME as moderate, >91 MME as high dose 1, 2, 3
• Prescribe separately from non-opioid analgesics to allow independent dose adjustments 1
• Provide 5 days maximum, not to exceed 7 days 1

Specific Opioid Selection for Refills

Preferred Agents

• Liquid oral morphine 10mg/5mL is preferred for postoperative refills due to scheduling advantages 1
• Immediate-release oxycodone, hydrocodone, or codeine combined with acetaminophen for moderate pain 1

Agents Requiring Caution or Specialist Involvement

• Avoid immediate-release oxycodone as first-line due to scheduling complexity 1
• Methadone only after failure of other opioids and only by clinicians with specific training 1, 2, 3
• Never prescribe modified-release preparations (including transdermal patches) without specialist consultation to exclude chronic post-surgical pain 1

Age-Specific Considerations

• Dose based on age rather than weight, with renal function consideration 1
• In patients >70 years or with renal failure, alternative opioids may be preferred per local policy 1

Mandatory Patient Education Before Refill

Safety Information

• Safe self-administration, weaning protocols, and disposal of unused medications 1
• Dangers of driving or operating machinery while taking opioids 1
• Secure storage to prevent diversion, particularly from children and household members 1
• Risks of respiratory depression, especially with concurrent benzodiazepines or alcohol 1, 4, 5

Monitoring Requirements

• Encourage patients to keep a record of analgesics taken - this improves pain control 1
• Provide written patient information leaflet 1

Adherence Monitoring for Ongoing Therapy

Required Monitoring

• PDMP checks at each refill consideration 1, 2
• UDT from initiation and throughout therapy 1, 2, 3
• Assessment of pain relief and functional improvement (≥30% improvement required) 2
• Monitor sedation scores and respiratory rate to detect opioid-induced ventilatory impairment 1

Special Monitoring for Specific Agents

• Electrocardiogram for methadone: prior to initiation, at 30 days, then yearly 2, 3
• Constipation monitoring with prophylactic bowel regimen (stimulant laxative preferred over stool softener alone) 1, 2

When to Involve Specialists

Pain Management Consultation Indicated

• High-dose opioid therapy consideration (>90 MME/day) 1, 2
• Opioid-tolerant patients requiring postoperative care 1
• Patients with substance use disorder requiring pain management 1
• Consideration of modified-release preparations 1
• Pain persisting >90 days post-surgery 6

Transitional Pain Services

• Opioid-tolerant patients after pain-relieving surgery requiring de-escalation 1
• Difficulties with analgesic weaning post-discharge 1

Critical Pitfalls to Avoid

Common Prescribing Errors

• Adding postoperative opioids to repeat prescription templates - this is the most dangerous error leading to inadvertent chronic therapy 1
• Prescribing beyond 7 days without documented medical necessity and specialist input 1
• Initiating or refilling with long-acting/extended-release formulations 1
• Combining opioids with benzodiazepines without careful justification 1, 4, 5

Monitoring Failures

• Failing to check PDMP before refill 1, 2
• Not performing UDT to verify adherence 1, 2, 3
• Missing aberrant drug-related behaviors 1, 2

Communication Failures

• Not providing timely discharge letters to all healthcare providers including pharmacists 1
• Failing to explicitly document dose, duration, and planned discontinuation 1
• Not educating patients on safe disposal leading to diversion risk 1

Discontinuation and Weaning

Reverse Analgesic Ladder

When analgesic requirements decrease, follow this sequence: 1

1. Wean opioids first
2. Then stop NSAIDs
3. Finally stop paracetamol (acetaminophen)

Indications for Discontinuation

• Lack of ≥30% improvement in pain and function 2
• Adverse consequences outweighing benefits 2
• Evidence of abuse or diversion 2
• Patient request or achievement of treatment goals 2

Safe Disposal

• Patients must return excess opioids to community or hospital pharmacy - never dispose at home 1
• Provide specific disposal instructions at time of prescribing 1