Transcript Presentation on safe opioid prescribing and opioid

Safe Opioid Prescribing and
Managing Opioid Use Disorders
Educational Rounds for
Primary Care Physicians
META:PHI 2015
About META:PHI
Mentoring, Education, and Clinical Tools for Addiction:
Primary Care–Hospital Integration
• Goals:
– Promote evidence-based addiction medicine treatment
– Implement care pathways between the ED, hospital, WMS,
primary care, and rapid access addiction medicine clinics
• Seven sites in Ontario are currently involved, with plans to
expand the spread of the project in the future
• Funding and support provided by the Adopting Research to
Improve Care (ARTIC) program (Council of Academic Hospitals
of Ontario & Health Quality Ontario)
https://www.porticonetwork.ca/web/meta-phi
META:PHI 2015
Sign-In Sheet
• META:PHI mailing list: Forum for project team and
other health care providers to discuss clinical cases,
policies, and events related to addiction
• All attendees invited to participate: Write name/email address on sheet to be added
META:PHI 2015
OVERVIEW
META:PHI 2015
Opioid Prescribing in Canada
• Drastic increase in Canadian opioid prescribing since
1990s
• Substantial increases in opioid overdose deaths and
prescription opioid addiction (1, 2)
• PCPs’ prescribing practices contribute to harms
• Set of evidence-based guidelines on opioid
prescribing for chronic pain were developed by the
National Opiate Use Guideline Group (3)
– These guidelines have had little effect on overprescribing
META:PHI 2015
Opioid Prescribing in Canada (cont’d)
• Canada is world’s 2nd largest per capita consumer of
opioids (4)
• Ontario highest annual rate of high-dose oxycodone
and fentanyl dispensing: 756 tablets and 112 patches
per 1000 (5)
• Opioid-related deaths in Ontario have risen from 127
in 1991 to 550 in 2010, a 242% rise (6)
META:PHI 2015
Minimizing Risks of Opioid Therapy
1. Only prescribe to patients for whom opioids are
likely to be safe and effective.
2. Always begin therapy with weak opioids.
3. When prescribing potent opioids, start with a low
dose and titrate slowly.
4. Routinely monitor patients on opioid medications
to ensure that they are experiencing meaningful
benefit.
5. Provide patients with education on safely storing
medication, preventing overdose, and the risks of
sharing opioids with others.
6. Initiate appropriate treatment or facilitate referral
for patients with an opioid use disorder.
META:PHI 2015
INITIATING OPIOID THERAPY
META:PHI 2015
Acute vs. Chronic Pain
• Severity of acute pain determined by severity and
extent of tissue damage/inflammation
– Acetaminophen, NSAIDs, opioids, local anesthetics,
and other treatments very effective
• In chronic non-cancer pain (CNCP), psychological and
cognitive factors influence pain perception
– Opioids and other analgesics only modestly effective
and rarely relieve pain completely
– Effective non-pharmacological approaches: cognitive
behavioural therapy, mindfulness meditation,
physical modalities
– Effective non-opioid medications: acetaminophen,
NSAIDs, anticonvulsants, antidepressants
META:PHI 2015
Opioids as Therapeutic Trial
• Opioid prescribing = therapeutic trial
– Continue if patient experiences meaningful
benefit:
• Improved function and reduction in pain severity
of 2+ points on a ten-point scale without
significant side effects
– Taper and discontinue if patient has failed
adequate trial of 2+ opioids; continued opioid
prescribing puts patients at risk for long-term side
effects and complications
META:PHI 2015
Indications for Long-Term Opioid Therapy
• Patient has well-defined pain condition (nociceptive
or neuropathic) that…
a. has been shown to respond to opioids
b. causes both pain and disability
• Non-opioid treatments are ineffective,
contraindicated, or have intolerable side effects
• Note: Potent opioids are not indicated for common
pain conditions such as fibromyalgia, low back pain,
and headaches
– Benefits are minimal and are outweighed by the side
effects
META:PHI 2015
Prior to Prescribing Opioids
• Ask about current and past use of alcohol and drugs
• Ask about mood
– Depressed patients may have heightened
perception of pain and are less responsive to
opioids
• Check renal and respiratory status, especially risk of
sleep apnea
• In elderly patients, assess risk of falls
• Consider tapering benzodiazepines
• Ask about the impact of pain on activities of daily
living
META:PHI 2015
Prior to Prescribing Opioids (cont’d)
• Reassess their response to non-opioid treatments:
– Nociceptive pain: acetaminophen, NSAIDs, SNRIs
– Neuropathic pain: anticonvulsants, SNRIs, TCAs
– All pain: Mindfulness programs, graded exercise
• Advise patients not to drink alcohol during titration
• Warn patients to avoid driving for at least two hours
after a dose in the first 1–2 weeks of treatment
initiation and the first week of dose increase
• Warn patients to keep their opioids safely stored
(especially if they live with adolescents/young
adults), and not to give any opioid medications to
relatives or friends
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Office Visits
• See patient frequently during initiation and titration
• At each office visit, ask about changes in:
– Work, school, social activities, daily activities
– Pain ratings on a 0–10 scale, at rest and with
activity
– Mood
• Ask about side effects:
– Sedation, dizziness, and other CNS effects
– Constipation, nausea
META:PHI 2015
OPIOID PRESCRIBING PROTOCOL
META:PHI 2015
Immediate Release (IR) vs. Controlled
Release (CR)
• Initiate opioid trial with IR preparations
• Maintain on IR for brief pain (less than 4 hours) or
incident pain (triggered by activity)
• For constant pain throughout the day, switch to CR
• In long-term therapy for constant pain throughout
the day, “breakthrough” IR medications should not
exceed 10–30% of total daily opioid dose
META:PHI 2015
Opioid Selection
• Always initiate opioid treatment with “weak”
opioids, i.e., oral preparations of codeine, tramadol
(e.g., Tramacet, Ultram, Zytram XL), or
buprenorphine patch (BuTrans)
• If insufficient analgesia with first-line opioids,
prescribe morphine (various generics), oxycodone
(various generics, OxyNEO), or hydromorphone
(e.g., Dilaudid, Hydromorph Contin, Jurnista)
• Note: Morphine is contraindicated in patients with
renal insufficiency
META:PHI 2015
Opioid Selection (cont’d)
• Some evidence suggests that hydromorphone and
oxycodone have fewer cognitive effects than
morphine in the elderly
• Prescribing transdermal fentanyl (various generics,
Duragesic) should be done with extreme caution,
especially in the elderly and patients at high risk for
opioid use disorder
– Use only if the patient has taken at least 60–100
mg morphine equivalent daily (MED) of a potent
opioid for at least 2 weeks
META:PHI 2015
Opioid Initiation and Dose Titration
Opioid
Max initial
dose
Max dose
increase
Min days
between
increases
Min IR dose
before moving
to CR
Codeine
200 mg/d
50 mg/d
7 days IR, 14
days CR
150 mg
Transdermal
buprenorphine
5 μg/7d
5 µg/7d
7 days
-------
Morphine*
40 mg/d
10 mg/d
7 days IR, 14
days CR
30 mg
Oxycodone*
30 mg/d
5 mg/d IR, 10
mg/d CR
7 days IR, 14
days CR
20 mg
Hydromorphone*
8 mg/d
1–2 mg/d IR, 2–
4 mg/d CR
7 days IR, 14
days CR
6 mg
Tapentadol*
IR 700 mg/d, 100 mg/d CR
CR**
3 days CR
-------
*Potent opioids should only be dispensed to patients currently taking weak opioids daily. All dose
increases should be based on individual assessment.
**CR: Start 50 mg bid in opioid-naïve, ≥50 mg bid if switching from other opioids. Maximum 250 mg bid.
META:PHI 2015
Exert caution when switching from pure mu-opioids.
Morphine Equivalency
Opioid
Analgesic equivalence value
Morphine (reference)
30 mg
Codeine
200 mg
Oxycodone
20 mg
Hydromorphone
6 mg
Tapentadol
No equivalence to morphine established, but
CR has demonstrated comparable pain relief
to oxycodone CR (dose ratio 5:1)
Transdermal buprenorphine No equivalence to morphine established
Transdermal fentanyl
25 μg/hr = 60–100 mg oral morphine per day
META:PHI 2015
Optimal Dose
• Increase dose if insufficient analgesia and no
improvement in function
• Optimal dose reached if:
– Pain relief at least 2 points on 10-point scale, with
no benefit from 1–2 additional dose increases
– Improved functioning at work, school, and with
family; increased physical activities
– No major side effects
• Optimal dose for most patients is 50–60 mg
META:PHI 2015
Maximum (“Watchful”) Dose
• Opioids have dose-related complications (e.g.,
overdose, sleep apnea, falls/fractures)
• Watchful dose given by the Canadian Guideline is
200 mg MED
• However, doses above 120 mg MED are strongly
associated with an increased risk of overdose
• At doses approaching 120 mg MED, reassess opioid’s
analgesic effectiveness and side effects, and decide
whether to maintain the dose or taper
META:PHI 2015
Minimizing Adverse Effects
1. Falls in the elderly
• Do not prescribe opioids to cognitively impaired
patients unless dispensed and overseen by caregiver
• Taper benzodiazepines
• Avoid use of opioids at night if possible
– If pain wakes patient up, prescribe smallest IR
opioid dose and warn patients to take extra
precautions when getting out of bed
META:PHI 2015
Minimizing Adverse Effects (cont’d)
2. Overdose during initiation/increase
• Educate patients on early signs of impending
overdose: sedation, slowed speech, nodding off
• Advise family to call 911 at first sign of overdose
3. Fatigue
• Opioids cause fatigue either through direct sedating
effect or by contributing to sleep apnea
– Assess for sleep apnea
– Reduce, discontinue, or switch opioid
META:PHI 2015
Minimizing Adverse Effects (cont’d)
4. Constipation
• Increase fibre, fluid, activity
• If laxatives are needed, consider polyethylene glycol
(Restorolax), sodium picosulphate (Dulcolax) or
lactulose
– Polyethylene glycol most effective for opioidinduced constipation
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OPIOID TAPERING AND SWITCHING
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Indications for Tapering
• Patient has persistent severe pain and pain-related
disability despite an adequate opioid dose (e.g., 60
mg/d MED), and patient has already failed on a trial
of at least one opioid previously
– Evidence suggests tapering improves pain, mood,
and functioning in these circumstances
• Patient has complication from opioid therapy (e.g.,
sleep apnea, sedation, dysphoria)
• Part of structured opioid therapy for patients who
are addicted or at high risk for addiction
META:PHI 2015
Key Principles of Tapering
• Taper by no more than 10% of total daily
dose every 1–2 weeks
• Keep dosing interval the same (e.g., tid, bid)
• Use scheduled rather than PRN dosing
• Endpoint of taper not necessarily abstinence
but improved functioning, mood, and/or pain
• Do not abruptly discontinue opioids under
any circumstances
– Risk of loss of tolerance and overdose
META:PHI 2015
Tapering Protocol
Formulation
CR preferred (until low dose reached)
Dosing interval
Scheduled doses rather than PRN
Keep dosing interval the same for as long as possible
Advise patients not to skip doses
Rate of taper
Taper slowly (max 10% of total daily dose every 1-2 weeks)
Let patient choose which dose is decreased (AM, PM, or HS)
Taper even more slowly when 1/3 of total dose is reached
Dispensing interval
If patient runs out early, increase frequency to weekly,
alternate day, or daily
Endpoint of taper
≥ 60 mg MED (suggested watchful dose in elderly; controls
pain with minimal side effects)
Frequency of visits
If possible, see patient prior to each dose decrease
Approach
Ask about withdrawal symptoms and benefits of tapering:
more alert, less fatigued, improved mood, improved pain
META:PHI 2015
Indications for Switching Opioids
• Inadequate analgesic response to current opioid
(< 2/10 pain relief, no improvement in function)
despite a reasonable dose (e.g., 60 mg MED)
– Patients who have had minimal analgesic
response to a moderate dose are unlikely to
benefit from further dose increases
• Adverse effects with current opioid (e.g.,
constipation, sedation, falls)
META:PHI 2015
Opioid Switching Protocol
• Because patient will not be fully tolerant to new opioid,
its MED should be 50% of MED of original
• Example: When switching patient from 40 mg/d of
oxycodone to hydromorphone:
–
–
–
–
40 mg/d oxycodone = 60 mg MED
60 mg MED = 12 mg/d hydromorphone
50% of hydromorphone 12 mg = 6 mg
Therefore, start patient on 6 mg/d in divided doses
• Ensure patient understands that taking extra doses is
dangerous
• Titrate dose as appropriate for opioid
META:PHI 2015
OPIOID MISUSE AND WITHDRAWAL
META:PHI 2015
Limiting Misuse and Diversion
• Warn patients to store medication in secure location,
not to show them to younger relatives, and not to
share them with anyone
• Avoid using fentanyl patches in elderly patients with
younger adults at home
– Used patches contain large amount of fentanyl;
patches can be lifted off patient’s skin while they
are sleeping
• Without anyone else present, ask parents and
grandparents on opioids if younger relatives could be
using their medication, especially if patient requires
high doses, runs out early, or is accompanied by
younger adult to office visits
META:PHI 2015
Features of Opioid Withdrawal
Time course
Symptoms start six hours after last use of IR opioid, peak at 2–3
days, and begin to resolve by 5–7 days (methadone withdrawal
peaks on day 5, and bup/nx withdrawal peaks on day 7)
Psychological symptoms can last for weeks
Physical symptoms
Flu-like: Myalgias, chills, sweating, nausea and vomiting,
abdominal cramps, diarrhea
Insomnia, anxiety and irritability, restlessness, dysphoria, craving
Psychological symptoms
Complications
a. Suicide
b. Overdose if opioids taken after a period of abstinence (loss of
tolerance)
c. Possible gastritis or peptic ulcer
d. Acute exacerbation of cardiorespiratory illnesses, e.g., asthma,
angina
e. Exacerbation of psychiatric conditions: anxious patients may
experience panic attacks, schizophrenic patients may experience
psychosis, etc.
META:PHI 2015
Prevention and Management of
Opioid Withdrawal
• Do not discontinue opioids abruptly; taper dose slowly
• If patient in acute withdrawal, buprenorphine/naloxone
(bup/nx) is safest and most effective treatment
– Prior to administering bup/nx, ensure patient has not
used opioids for at least 12–16 hours, and patient
reports symptoms of withdrawal
– Clinical Opioid Withdrawal Scale (COWS) used to
monitor withdrawal severity (assess at baseline and at
30m, 2h, 4h)
– Initial dose 2 mg sublingual (SL)
– Dispense 2–4 mg SL in 2 hours if necessary; maximum
4 mg on first day
– May taper over several
days/weeks or maintain dose
META:PHI 2015
Clinical Opioid Withdrawal Scale
(COWS) (7)
Resting heart rate (measure after
lying or sitting for one minute)
0 HR ≤ 80
1 HR 81–100
Sweating (preceding 30m and not
related to room temp/activity)
0 no report of chills or flushing
1 subjective report of chills or flushing
2 flushed or observable moistness on face
3 beads of sweat on brow or face
4 sweat streaming off face
Restlessness (observe during
assessment)
0 able to sit still
1 reports difficulty sitting still, but is able to do so
3 frequent shifting or extraneous movements of
legs/arms
5 unable to sit still for more than a few seconds
Pupil size
0 pupils pinned or normal size for room light
1 pupils larger than normal for room light
2 pupils moderately dilated
5 pupils so dilated that only the rim of the iris is visible
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2 HR 101–120
4 HR > 120
COWS (cont’d)
Bone or joint pain (not
including existing joint pains)
0 not present
1 mild diffuse discomfort
2 patient reports severe diffuse aching of joints/ muscles
4 patient is rubbing joints / muscles plus unable to sit still
due to discomfort
Runny nose or tearing (not
related to URTI or allergies)
0 not present
1 nasal stuffiness or unusually moist eyes
2 nose running or tearing
4 nose constantly running or tears streaming down cheeks
GI upset (over last 30 minutes)
0 no GI symptoms
1 stomach cramps
2 nausea or loose stool
3 vomiting or diarrhoea
5 multiple episodes of vomiting or diarrhoea
Tremor (observe outstretched
hands)
0 no tremor
1 tremor can be felt, but not observed
2 slight tremor observable
4 gross META:PHI
tremor2015
or muscle twitching
COWS (cont’d)
Yawning (observe during
assessment)
0 no yawning
1 yawning once or twice during assessment
2 yawning 3+ times during assessment
4 yawning several times/minute
Anxiety or irritability
0 none
1 patient reports increasing irritability or anxiousness
2 patient obviously irritable or anxious
4 patient so irritable or anxious that participation in the
assessment is difficult
Gooseflesh skin
0 skin is smooth
3 piloerection (goosebumps) of skin can be felt or hairs
standing up on arms
5 prominent piloerection
SCORE INTERPRETATION
5-12
13-24
Mild
Moderate
META:PHI 2015
25-36
> 36
Moderately severe
Severe
OPIOID ADDICTION
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Identifying Patients
• OUDs are difficult to diagnose if patient doesn’t
disclose use
• Maintain high index of suspicion with risk factors:
– Younger, male, psychiatric comorbidity, concurrent
or past addiction to other drugs, on high
prescribed opioid doses
• Common presentations:
– Overdose, withdrawal, drug seeking, infections
from injection drug use, depression and suicidal
ideation, trauma
META:PHI 2015
Indications of an OUD
1. Check for physical signs of opioid use: track
marks, pinpoint pupils, slurred speech, nodding
off (intoxication), restlessness (withdrawal)
2. Check pharmacy dispensing record for patients
on Ontario Drug Benefits
3. Ask about opioid use and withdrawal symptoms
META:PHI 2015
Symptoms and Behaviours of Problematic
Opioid Use
• Patient’s opioid dose high for underlying pain condition
• Aberrant behaviours: Running out early, crushing/biting
oral tabs, accessing opioids from other sources
• Importance patient attaches to drug far outweighs
analgesic benefit (e.g., strong resistance to tapering or
switching current opioid)
• Binge rather than scheduled opioid use
• May be currently addicted to other drugs, e.g., alcohol
META:PHI 2015
Symptoms and Behaviours of
Problematic Opioid Use (cont’d)
•
•
•
•
•
Depressed and anxious
Deteriorating mood and functioning
Concerns expressed by family members
Reports recurrent, frightening withdrawal symptoms
May acknowledge that they experience immediate
improvement in mood after taking opioid
META:PHI 2015
Presenting OUD Diagnosis
• Be clear and non-judgmental
• Inform patient that their opioid use is harming them,
and that treatment will improve their pain, mood,
and functioning
• Refer patient to treatment
– Tell patient that if they do not engage in treatment
you will perform an involuntary taper
• Do not abruptly stop opioid prescribing
– Taper dose with frequent (i.e., daily) dispensing
META:PHI 2015
OUD Management Options
1. Abstinence-based psychosocial treatment
2. Structured opioid therapy
3. Opioid maintenance therapy
META:PHI 2015
Abstinence-Based Psychosocial Treatment
• Cessation of all alcohol and drugs (including opioid
maintenance drugs methadone and bup/nx)
• Less effective than opioid maintenance but often
preferred by patients, and is sometimes a requirement
for probation, etc.
• Patients at increased risk for opioid overdose after
leaving abstinence-based programs, so overdose
prevention strategies are needed:
– Do not inject
– Take a much smaller opioid dose than usual
– Take a test dose unless you got the drug directly from a doctor’s
prescription
– Don’t mix opioids with alcohol/benzodiazepines
– Always have a friend with you if you inject or snort opioids –
don’t use alone
META:PHI 2015
Structured Opioid Therapy
• Continued opioid prescribing under conditions that limit
misuse
• Preliminary evidence: effective, convenient for patients, and
easier to organize than opioid substitution therapy
• Refer for opioid substitution therapy if structured therapy fails
• Indications:
– Addicted to opioids or at high risk for addiction (younger,
personal or strong family history of addiction, anxiety or
mood disorder)
– Has pain condition requiring opioid therapy
– Only uses opioids supplied by one physician
– Does not alter route of delivery (inject or crush oral tabs)
– Is not currently addicted to alcohol or other drugs
META:PHI 2015
Structured Opioid Therapy (cont’d)
• Protocol:
– Taper dose to below 200 mg MED (emphasize that
patient will feel and function better with lower dose)
– Dispense small amounts frequently (e.g., 1–2 times
per week)
– Do not refill if patient runs out early
– Monitor closely with urine drug screens, pill counts,
office visits
– Switch to opioid maintenance therapy if structured
opioid therapy fails (e.g., patient continues to access
opioids from other sources)
META:PHI 2015
Opioid Maintenance Therapy
• Substituting illegal and/or euphoria-inducing opioid
with longer-acting, less euphoric opioid (i.e.,
methadone or bup/nx)
• Indications:
– Failed at or not a candidate for structured opioid
therapy
– Acquires opioids from multiple sources (e.g., other
doctors, friends and relatives, the street)
– Injects or crushes oral tablets
– Currently misusing alcohol or other drugs
META:PHI 2015
PRESCRIBING
BUPRENORPHINE/NALOXONE
META:PHI 2015
Buprenorphine
• Partial opioid agonist with ceiling effect
– Unlike full agonists (e.g., morphine), even very
high doses rarely cause respiratory depression
unless combined with alcohol/sedating drugs
• Appropriate dose relieves withdrawal symptoms and
cravings for 24 hours without causing euphoria
• Binds very tightly to the opioid receptors, displacing
other opioids that occupy the receptor site
– Minimizes psychoactive effect of other opioids
taken concurrently
• Has slow onset and long duration of action
• Side effects similar to other opioids: nausea,
constipation, sedation
META:PHI 2015
Initiation Protocol
• Physician must ensure that patient has no opioid in their serum
before taking the first dose to avoid precipitated withdrawal
– Precipitated withdrawal is rarely severe or dangerous, but
patients who experience it are reluctant to try bup/nx again
• Give first dose in office setting, if feasible
– 12-16 hours since last IR dose, 24 hours since last CR dose
– Patient reports typical withdrawal symptoms
– COWS score of 12+
• First dose: 4 mg SL (dose may take several minutes to dissolve)
• Reassess in 2 hours.
– If patient improved but still in withdrawal, give another 4 mg
to take in office or at home
– Maximum dose first day: 12 mg
META:PHI 2015
Initiation Protocol (cont’d)
• Reassess in 1–3 days
– Increase dose by 2–4 mg at each visit if patient
reports withdrawal symptoms or cravings towards
end of dosing interval
– Each dose increase should increase duration of
relief from withdrawal and cravings
• Optimal maintenance dose usually 8–16 mg SL OD;
maximum dose 24 mg SL OD
– Optimal dose should relieve withdrawal symptoms
and cravings for 24 hours without causing
significant sedation or other side effects
META:PHI 2015
Initiation Protocol (cont’d)
• At beginning of therapy, bup/nx should be dispensed
daily under observation by pharmacist
– If patient unable to attend daily, arrange
supervised dispensing at home by nurse or
reliable relative
– Take-home doses may be prescribed once patient
is at optimal dose and has stopped unauthorized
opioid use
• Arrange frequent office visits for counselling and
urine drug screen monitoring
META:PHI 2015
Bup/nx Prescriptions
•
•
•
•
•
Patient’s name, date of birth, and health card number
Pharmacy address and fax number
Dose
Start and end dates
Days of the week patient takes dose at pharmacy under
observation of pharmacist, and days patient takes dose at home
– Stable patients usually attend pharmacy once a week to take
one observed dose and take six doses home
• Limited use (LU) code for patients on ODB: 437 (for patients who
have failed, have significant intolerance of, have a
contraindication to, or are at high risk for toxicity with
methadone) or 438 (when a methadone maintenance program
is not available or accessible)META:PHI 2015
Sample Bup/nx Prescription
Jennifer Chen MD
Main St. Clinic
Phone: (555) 555-1234
Fax: (555) 555-1237
Date: June 2, 2016
Jonathan Smith
HC 1234 567 890 QI
DOB Apr. 25, 1974
Shoppers Drug Mart, 123 Elm St.
Fax: (555) 555-9834
Buprenorphine/naloxone 8/2 mg 1 tab SL OD
June 2, 2016 – June 8, 2016 inclusive
Dispense daily observed
LU 437
Jennifer Chen MD
CPSO 12345
META:PHI 2015
Management of Stable Patients on
Bup/nx
• Ask about withdrawal symptoms or cravings
– Sometimes patients require minor dose adjustments of 2–4
mg/day
• Ask about alcohol and cannabis use (usually not tested
on urine drug screen)
• Ask about overall mood and functioning
• Manage chronic medical conditions (e.g., hepatitis C) or
psychiatric conditions (e.g., anxiety, depression)
• Perform regular screening and health maintenance (e.g.,
pap tests, mammograms, immunizations, etc.)
META:PHI 2015
Urine Drug Screening
• Review urine drug screen results
– Stable patients should leave one urine sample per month
– Review unexpected results with patient and, if necessary,
with addiction physician
Result
Interpretation
Absence of
norbuprenorphine
Noncompliance or
diversion
Presence of opioids or
benzodiazepines
Presence of cocaine or
crystal methamphetamine
Action
If diversion suspected, resume daily supervised
dispensing
Consider consult with addiction physician
Innocent slip
If inadvertent, warn patients not to take meds from
Early relapse
family or friends
Increase testing frequency
If meds used for mood control:
 Assess adequacy of bup/nx dose
 Counsel about avoiding triggers
 Assess mood
 Increase testing frequency
 If persists, reduce number of take-home doses
Possible stimulant use
Consider consult with addiction physician
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disorder
Tapering Bup/nx: Indications
• Patient wants to taper
• Patient has at least six months without any
substance use
• Patient is socially stable and has a supportive family
or social network
• Patient has a stable mood and good coping strategies
• Patient has minimal contact with drug users
META:PHI 2015
Tapering Bup/nx: Protocol
• Decrease by small amounts, e.g., 2 mg or even 1 mg
(half of a 2 mg tablet) at a time
• Leave at least two weeks, preferably longer, between
dose decreases
• Put taper on hold at patient’s request, or if patient
experiences withdrawal symptoms or cravings
• Return to original dose if patient begins using opioids
again, even in small amounts or intermittently
• Provide regular support and encouragement
• Emphasize that it is not a “failure” if taper has to be
held or reversed, and it is safe and acceptable to
remain on bup/nx for long periods when necessary
META:PHI 2015
References
1.
2.
3.
4.
5.
6.
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Avoiding abuse, achieving a balance: tackling the opioid public health
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Canadian Guideline for Safe and Effective Use of Opioids for Chronic
Non-cancer Pain. National Opioid Use Guideline Group, 2010. Canada:
National Opioid Use Guideline Group, 2010.
International Narcotics Control Board. Narcotics Drugs: Estimated World
Requirements for 2013; Statistics for 2011. 2013. New York: United
Nations.
Gomes T, Mamdani MM, Paterson JM, et al. Trends in high-dose opioid
prescribing in Canada. Can Fam Physician 2014;60:826-32.
Gomes T, Mamdani MM, Dhalla IA, Cornish S, Paterson JM, Juurlink DN.
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