How to handle after-hours requests for narcotic (opioid) refills?

Managing After-Hours Narcotic Refill Requests

After-hours narcotic refill requests should be declined, with the patient instructed to contact their primary prescriber during regular business hours or present to the emergency department for evaluation if they are experiencing acute pain or withdrawal symptoms that require immediate assessment.

Core Principle: Avoid Automatic Refills

Repeat and refill prescriptions of opioids are one of the major modifiable risk factors for persistent opioid use, with each additional refill increasing the risk of opioid misuse by 40% and each additional week of opioids raising the risk by 20%. 1 Any request for more opioids should initiate a patient review rather than an automated repeat prescription. 1

Recommended Response Protocol

Immediate Response to After-Hours Call

• Decline to prescribe opioids without direct patient evaluation. The after-hours setting prevents proper assessment of pain etiology, review of prescription drug monitoring programs (PDMPs), and evaluation for potential substance use disorder. 1

• Instruct the patient to contact their primary prescriber during regular business hours for medication management and reassessment of their pain control regimen. 1

• Direct patients with acute, severe pain to the emergency department where they can receive appropriate evaluation and short-term management if clinically indicated. 1

Key Rationale for This Approach

• Opioid prescriptions should be limited in duration (typically 3-5 days, maximum 7 days) with no automatic refills or repeats to minimize the risk of persistent postoperative opioid use and diversion. 1

• Patients requiring opioids beyond the normal healing period for their condition should be referred to pain specialists rather than receiving continued refills. 1

• Rapid discontinuation of opioids in physically dependent patients can result in serious withdrawal symptoms, uncontrolled pain, and suicide, but this risk must be balanced against the harms of inappropriate prescribing. 2

Assessment of Withdrawal vs. Pain

If Patient Reports Withdrawal Symptoms

• True opioid withdrawal is a medical condition that requires evaluation, not telephone management. 1, 3

• Patients in active opioid withdrawal should present to the emergency department where they can be assessed using standardized tools like the Clinical Opiate Withdrawal Scale (COWS) and potentially initiated on medication-assisted treatment with buprenorphine if appropriate. 1, 3

• Buprenorphine can be administered in the ED setting for patients with COWS scores >8 (moderate to severe withdrawal), with initial doses of 4-8 mg sublingual. 1, 3

If Patient Reports Inadequate Pain Control

• Patients requiring opioids beyond expected recovery timelines need comprehensive reassessment, not telephone refills. 1

• If the patient is still requiring postoperative opioids beyond the normal healing period or taking opioids 90 days after surgery, they should be referred to pain specialists for evaluation of chronic postsurgical pain. 1

Common Pitfalls to Avoid

Do Not Provide "Bridge" Prescriptions

• Even small "bridge" prescriptions contribute to the risk of persistent opioid use and undermine appropriate pain management strategies. 1

• Each additional week of opioid therapy increases misuse risk by 20%, making even short-term extensions problematic. 1

Do Not Assume Drug-Seeking Behavior

• Classic "drug-seeking behaviors" occur with only low to moderate frequency even in confirmed drug-seeking patients (averaging 1.1 behaviors per visit). 4

• Patients with undertreated chronic pain (pseudoaddicts) may exhibit behaviors that mimic drug-seeking but reflect inadequate pain management rather than substance use disorder. 5

• The distinction between addiction, physical dependence, and inadequate pain control requires in-person evaluation, not telephone assessment. 2, 5

Documentation Requirements

• Document the after-hours contact, your recommendation to contact the primary prescriber, and any instructions given regarding emergency department evaluation if needed. 1

• Note any concerning features such as reports of lost/stolen medications (which occurred in only 0.6% of visits even among known drug-seeking patients). 4

Special Circumstances Requiring Immediate ED Referral

• Patients reporting severe withdrawal symptoms (tremors, seizures, severe autonomic instability) require emergency evaluation. 1, 3

• Patients on methadone maintenance who have missed doses require specialized management and should not receive other opioids without proper assessment. 1, 3

• Patients with acute pain conditions (trauma, acute surgical complications, acute medical conditions) require emergency evaluation, not telephone prescribing. 1

Communication Strategy

• Be empathetic but firm in explaining that telephone prescribing of controlled substances without evaluation is not appropriate medical practice. 1

• Emphasize patient safety as the reason for requiring in-person evaluation before any opioid prescribing. 1

• Provide clear next steps (contact primary prescriber during business hours or present to ED if urgent). 1