Table 6

Management of opioid misuse or addiction

PATIENT CATEGORYMANAGEMENT
High risk of addiction (eg, past history of addiction)

  • Use opioids only if first-line treatments fail

  • Prescribe small amounts

  • Perform frequent UDS

  • Use caution with oxycodone and hydromorphone

  • Keep dose well below a 200-mg/d MED

Currently addicted to other drugs (eg, alcohol)

  • Opioids usually contraindicated

  • Refer for formal addiction treatment (methadone or buprenorphine)

Suspected opioid misuse and

  • has organic pain requiring opioid therapy

  • family physician is only source of opioids

  • does not inject or crush tablets

  • is not currently addicted to cocaine, alcohol, or other drugs

Trial of structured opioid therapy:

  • Dispense frequently (daily, alternate days, or twice per week)

  • Regular UDS (1–4 times/mo)

  • Pill or patch counts

  • Switch the patient to controlled-release preparations

  • Avoid parenteral use and short-acting agents

  • Consider switching to a different opioid, while avoiding oxycodone and hydromorphone

  • Taper if on dose above the 200-mg/d MED

Suspected opioid misuse and

  • fails or is not eligible for a structured opioid trial (eg, injecting tablets, addicted to other drugs, or acquiring opioids from other sources)

Methadone or buprenorphine treatment:

  • Institute daily supervised dispensing

  • Gradually introduce take-home doses

  • Frequent UDS

  • Provide counseling and medical care

  • MED—morphine equivalent dose, UDS—urine drug screening.

  • Reprinted from Mailis-Gagnon and Kahan.21