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Prescribing opioids to patients at high risk of addiction

Some patients at high risk of addiction (e.g., those with a history of serious mental illness or a history of addiction to non-opioid substances) may nonetheless be eligible for a trial of opioid therapy for chronic non-cancer pain if they have a well-defined nociceptive or neuropathic pain condition that has not responded to non-opioid alternatives.

Minimizing adverse outcomes

Use the following strategies to minimize adverse outcomes in patients at high risk of addiction:

  • Educate patients about the risks and safe use of opioids. Also ensure that patients have realistic expectations about what opioids will be able to accomplish (i.e., reduce, not eliminate, pain).
  • Start with a weaker opioid (i.e., codeine, tramadol), start with lower doses and titrate slowly.
  • Follow established guidelines about dose titration.
  • Write prescriptions such that medication is dispensed in small quantities, (e.g., daily, every second day or weekly). This allows frequent assessments by the pharmacist and minimizes the possibility of running out early or of diversion.
  • Monitor patients frequently through clinical assessments, and order urine drug tests when appropriate.
  • Have an "exit strategy": Know what you will do if the patient does not respond as you would expect, has significant adverse effects or displays persistent drug-related aberrant behaviours.
  • Use a written treatment agreement. See the sample contract from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain.
  • Do regular urine drug testing – weekly in the beginning, transitioning to less often if the patient does not display any drug-related aberrant behaviours.

Key safety messages

Make sure that patients understand these key safety messages about taking opioids:

  • It is not safe to take more medication than prescribed.
  • Keep the medication away from others, particularly adolescents or young adults living in the same household. A dose that may be safe for the patient could be dangerous or even fatal for a non-tolerant person.
  • Do not mix opioids with alcohol or sedating medications such as benzodiazepines or dimenhydrinate (Gravol).
  • After a dose increase, do not drive until you know how the dose change affects you.
  • For family members: Contact the physician or emergency services if the patient shows signs of overdose (i.e., drowsiness, nodding off), especially during early titration.

Monitoring patients at high risk

Assess patients frequently during the initial titration.

Ask about and observe the five As:

Analgesic effects: "How well does the medication relieve your pain?" (using an 11-point scale, 0–10). Remember that in managing chronic non-cancer pain, a reduction in pain of 30 per cent, or two points on an 11-point scale, is considered significant (National Opioid Use Guideline Group, 2010).

Activity: "Are you more or less active since your last visit?" Activity rates should increase with improved analgesia.

Affect: "How is your mood?" Affect should get better with improved analgesia.

Adverse effects: "Are you feeling more sleepy than usual?" "Are you having any trouble with constipation?"

Aberrant behaviours: "Do you alter how you take the medication?" "Do you ever take more than is prescribed?"

Consider periodic urine drug tests and pill or patch counts.