Do I need to prescribe opiates to a patient with undisclosed long-term opiate use for chronic pain or can I refer them directly to a pain management specialist?

Managing Undisclosed Long-Term Opioid Use: Direct Referral vs. Continued Prescribing

You are not obligated to continue prescribing opioids to this patient and can refer directly to pain management, but you must avoid patient abandonment by ensuring continuity of care during the transition. 1

Your Legal and Ethical Position

• You have no obligation to continue prescribing opioids that you did not initiate, particularly when the patient withheld this critical information during initial evaluation. 2
• However, you must ensure the patient is not abandoned—this means providing appropriate transition care and confirming the pain management specialist will accept the patient before discontinuing prescriptions. 1
• Abruptly discontinuing opioids in a patient on long-term therapy creates significant risks including withdrawal, mental health crisis, and potential overdose if the patient seeks opioids elsewhere. 1

Immediate Assessment Required

Before making your decision, you must determine:

• Current morphine milligram equivalent (MME) daily dose to assess overdose risk—patients on ≥90 MME/day are at substantially higher risk and require more urgent specialist involvement. 1
• Presence of concurrent CNS depressants (benzodiazepines, sedatives, alcohol) which dramatically increase overdose risk. 1
• Signs of opioid use disorder including difficulty controlling use, continued use despite harm, or evidence of diversion. 1
• Review prescription drug monitoring program (PDMP) data to identify undisclosed prescribers or concerning patterns. 1

Two Acceptable Pathways Forward

Option 1: Direct Referral to Pain Management (Preferred if feasible)

• Contact the pain management specialist directly to confirm they will accept the patient and obtain a specific appointment date before your last prescription runs out. 1
• Provide a short-term bridge prescription (typically 1-4 weeks) at the current dose to prevent withdrawal while the patient transitions to the specialist. 1
• Document your rationale: undisclosed long-term opioid use, lack of established treatment relationship, need for specialized pain management expertise. 1
• Provide the patient with written information about the referral, appointment details, and the limited duration of your bridge prescription. 1

Option 2: Temporary Management with Structured Plan

If immediate specialist access is unavailable (common in many areas), you may need to provide temporary management:

• Reevaluate the patient within 1-4 weeks to assess whether opioids are meeting treatment goals for pain and function. 1
• Establish clear treatment goals and document whether current therapy provides clinically meaningful improvement in function, quality of life, or pain. 1, 3
• Implement additional precautions if dose is ≥50 MME/day: increased monitoring frequency, urine drug screening, PDMP checks, and naloxone prescription. 1
• Make continued prescribing explicitly conditional on attending the pain management consultation and following through with specialist recommendations. 1

Critical Safety Measures During Transition

• Never abruptly discontinue opioids—this increases risk of overdose, mental health crisis, and the patient seeking opioids from unsafe sources. 1
• Prescribe naloxone for overdose reversal, particularly if the patient is on ≥50 MME/day or taking concurrent CNS depressants. 1
• If the patient is on ≥90 MME/day, explain in a nonjudgmental manner that evidence shows increased overdose risk at higher doses and that specialist evaluation is necessary. 1
• Document all discussions, your clinical reasoning, and the transition plan in detail to protect against allegations of patient abandonment. 1

Common Pitfalls to Avoid

• Do not make "cold referrals" where you simply give the patient a phone number without confirming the specialist will accept them—this constitutes abandonment. 1
• Do not continue prescribing indefinitely out of fear of conflict—this perpetuates potentially harmful therapy and increases your liability. 4, 5
• Do not taper or reduce the dose during the transition period unless there are immediate safety concerns (signs of overdose, severe sedation)—tapering should be managed by the accepting specialist. 1
• Do not discharge the patient without ensuring continuity of care—if no specialist is available, you may need to continue management while implementing CDC guidelines for risk mitigation. 1

Special Circumstances Requiring Different Approach

• If you suspect opioid use disorder (not just physical dependence), refer to addiction medicine rather than pain management, as these patients may benefit from buprenorphine or methadone maintenance. 1, 6
• If there is evidence of diversion or criminal activity, you should not prescribe at any dose and should document your concerns while still avoiding abandonment by facilitating appropriate referrals. 1
• If the patient refuses specialist referral, document this refusal and explain that you cannot continue prescribing without specialist input given the undisclosed nature of the therapy and associated risks. 1