What is the protocol for opiate management in patients with chronic pain or opioid use disorder?

Opiate Management Protocol

For chronic pain, start with immediate-release opioids at the lowest effective dose (5-15 mg oral morphine equivalent), maximize nonopioid therapies, reassess every 3 months, and avoid exceeding 50 MME/day without careful justification; for opioid use disorder, offer medication-assisted treatment with buprenorphine or methadone while addressing concurrent pain through multimodal approaches. 1

Initial Assessment and Patient Selection

Before initiating opioid therapy, conduct a comprehensive evaluation focusing on:

• Pain characteristics: Document baseline pain intensity, functional limitations, and specific pain syndrome (neuropathic vs. nociceptive) 1
• Risk stratification: Screen for opioid use disorder using DSM-5 criteria, assess history of substance use disorder, mental health conditions (particularly depression), and concurrent use of benzodiazepines or other CNS depressants 1
• PDMP review: Check prescription drug monitoring program database to identify existing opioid prescriptions and cumulative dosages that may increase overdose risk 1
• Functional goals: Establish specific, measurable treatment objectives beyond pain reduction (e.g., return to work, improved sleep, increased physical activity) 1

Opioid Initiation for Chronic Pain

Starting Regimen

Begin with immediate-release formulations only—never start with extended-release/long-acting opioids: 1

• Opioid-naïve patients: Start with 5-15 mg oral morphine sulfate (or equivalent) for breakthrough pain 1
• Dosing strategy: Prescribe "as needed" rather than scheduled dosing (e.g., "hydrocodone 5 mg/acetaminophen 325 mg, one tablet every 4 hours as needed" not "every 4 hours") 1
• Duration limits: For acute pain, prescribe no more than 3-7 days of opioids; avoid prolonged use beyond the acute pain episode 1

Critical Dosage Thresholds

Exercise extreme caution at specific MME levels: 1

• 50 MME/day: Carefully reassess risk-benefit ratio before crossing this threshold 1
• 90 MME/day: Avoid this dosage or provide explicit clinical justification; overdose risk increases substantially 1
• Dose escalation: If increasing dose, do so by 10-20% increments only after confirming inadequate analgesia despite optimal nonopioid therapy 1

Concurrent Therapies (Mandatory)

Maximize nonopioid approaches before and during opioid therapy: 1

• Pharmacologic: NSAIDs, acetaminophen, gabapentinoids for neuropathic pain, topical agents 1
• Nonpharmacologic: Physical therapy, cognitive-behavioral therapy, exercise therapy, interventional procedures as appropriate 1
• Constipation prophylaxis: Initiate stimulant laxatives (not just stool softeners) at opioid start; 40-80% of patients develop opioid-induced constipation 1

Monitoring and Reassessment

Frequency of Follow-up

Reassess at minimum every 3 months for stable patients; more frequently for high-risk patients: 1

• High-risk patients (≥50 MME/day, concurrent benzodiazepines, mental health conditions, substance use history): Evaluate monthly or more often 1
• Assessment components: Pain intensity (using validated scales like PEG), functional improvement toward established goals, adverse effects (sedation, constipation, cognitive impairment), signs of opioid use disorder 1

Warning Signs Requiring Immediate Action

Identify early indicators of problems: 1

• Overdose risk: Sedation, slurred speech, confusion, respiratory depression 1
• Opioid use disorder: Craving, taking opioids in greater quantities than prescribed, difficulty controlling use, continued use despite harm 1
• Lack of benefit: No sustained improvement in pain AND function after adequate trial 1

Opioid Tapering and Discontinuation

Indications for Tapering

Reduce or discontinue opioids when: 1, 2

• No clinically meaningful improvement in pain and function despite adequate trial 1
• Patient on high-risk regimen (≥50 MME/day or opioids plus benzodiazepines) without clear benefit 1
• Serious adverse events occur (overdose, hospitalization) 1
• Patient requests dose reduction 1

Tapering Protocol

Never abruptly discontinue opioids in physically dependent patients—this causes serious withdrawal and increases suicide risk: 2

• Standard taper rate: Reduce by 10% of the original dose per week as starting point 1
• Slower tapers: For patients on long-term therapy (years), consider 10% per month to improve tolerability 1
• Interval: Proceed with dose-lowering every 2-4 weeks; patients on shorter-term therapy may tolerate faster tapers 2
• Withdrawal monitoring: Assess for restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, mydriasis, anxiety, insomnia, GI symptoms 2
• Taper adjustment: If withdrawal symptoms emerge, pause taper or increase dose back to previous level, then proceed more slowly 2

Common pitfall: Rapid tapers (over 2-3 weeks) should be reserved only for severe adverse events like overdose 1

Management of Opioid Use Disorder

Medication-Assisted Treatment (First-Line)

Offer evidence-based medication treatment—this is the priority intervention: 1, 3

• Buprenorphine: Preferred for office-based treatment; partial agonist with ceiling effect on respiratory depression 1
• Methadone: Requires specialized clinic; full agonist effective for both OUD and pain 1
• Naltrexone: Consider only after complete opioid detoxification 1

Do not discontinue medication-assisted treatment during acute pain episodes—this worsens pain due to opioid withdrawal-induced hyperalgesia: 3

Pain Management in Patients on Buprenorphine

Buprenorphine's high μ-receptor affinity creates unique challenges: 1

1. First approach: Increase buprenorphine dose in divided doses (4-16 mg every 8 hours has shown benefit for chronic pain) 1
2. Second approach: Switch from buprenorphine/naloxone to transdermal buprenorphine alone (bypasses first-pass metabolism, may provide better analgesia) 1
3. Third approach: Add long-acting full agonist (fentanyl, morphine, hydromorphone) at higher-than-usual doses due to buprenorphine's receptor blockade 1
4. Last resort: Transition from buprenorphine to methadone maintenance if above strategies fail 1

Pain Management in Patients on Methadone

Continue usual methadone maintenance dose—verify with patient's clinic: 3

• For acute pain: Use conventional analgesics including additional opioids when necessary; reassure patients their addiction history will not prevent adequate pain treatment 3
• Avoid: Mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they precipitate withdrawal 3

Special Populations and Considerations

Opioid-Tolerant Patients with Breakthrough Pain

Calculate 24-hour opioid requirement and increase rescue dose by 10-20%: 1

• Reassessment timing: Every 60 minutes for oral opioids, every 15 minutes for IV opioids 1
• Dose adjustment: If pain unchanged/increased, give 50-100% of previous rescue dose 1
• Route change: Consider switching from oral to IV if pain remains uncontrolled after 2-3 cycles 1

Naloxone Co-Prescribing

Offer naloxone particularly when: 1

• Patient or household member has overdose risk factors 1
• Dosage ≥50 MME/day 1
• Concurrent benzodiazepine or other CNS depressant use 1
• History of substance use disorder 1

Avoiding Benzodiazepine-Opioid Combinations

Use extreme caution—this combination dramatically increases overdose risk: 1

• Avoid prescribing benzodiazepines with opioids whenever possible 1
• If both necessary, use lowest effective doses and closest monitoring 1

Patient Education (Mandatory Before Prescribing)

Discuss the following before initiating opioids: 1

• Serious risks: Potentially fatal respiratory depression, opioid use disorder, death at higher dosages 1
• Common effects: Constipation (initiate prophylaxis), drowsiness, nausea, tolerance, physical dependence 1
• Functional impairment: Effects on driving ability, especially with dose increases or concurrent CNS depressants 1
• Overdose risk: Increased with benzodiazepines, alcohol, illicit drugs, or other opioids 1
• Storage and disposal: Secure/locked storage; safe disposal of unused medication to prevent household member access 1
• Tapering plan: Importance of working toward discontinuation as pain resolves 1

Managing Suspected Drug-Seeking Behavior

Distinguish between legitimate pain needs and opioid use disorder: 3

• Assessment approach: Conduct careful clinical assessment for objective pain evidence; avoid allowing manipulation concerns to cloud judgment about genuine pain needs 3
• Pseudoaddiction recognition: Patients with undertreated pain may appear drug-seeking; adequate analgesia resolves these behaviors 3
• For patients on OUD treatment: Continue maintenance therapy, use conventional analgesics including opioids when necessary for acute pain, address patient anxiety about stigmatization through nonjudgmental discussion 3
• If OUD identified: Offer or arrange evidence-based treatment (buprenorphine or methadone plus behavioral therapy); do not simply discontinue opioids 3

Critical Pitfalls to Avoid

• Never start with extended-release/long-acting opioids—always use immediate-release formulations initially 1
• Never prescribe methadone or transdermal fentanyl unless thoroughly familiar with their unique pharmacokinetics and risks 1
• Never abruptly discontinue opioids in dependent patients—this causes withdrawal, uncontrolled pain, and increases suicide risk 2
• Never discontinue medication-assisted treatment during pain episodes—this worsens pain through withdrawal-induced hyperalgesia 3
• Never ignore chronic pain in OUD treatment programs—unmanaged pain is a primary factor in opioid relapse (43.2% of patients) 4
• Never exceed 90 MME/day without explicit justification—overdose risk increases substantially 1