Identification and Treatment of Prescription Opioid Dependent Patients


Indicators

Indicators that suggest the possibility of dependence should be explored in those on a long term opioid prescription:

  • Long-term prescribing of opioids for non-cancer conditions.
  • Current or past psychiatric illness or profound emotional trauma.
  • Reports of concern by family members or carers about opioid use.
  • Concerns expressed by a pharmacist or other healthcare professionals about long-term opioid use.
  • Insistence that only opioid treatment will alleviate pain and refusal to explore other avenues of treatment.
  • Refusal to attend or failure to attend appointments to review opioid prescription.
  • Resisting referral for specialist addiction assessment.
  • The repeated seeking of prescriptions for opioids with no review by a clinician.
  • Repeatedly losing medications or prescriptions.
  • Taking doses larger than those prescribed or increasing dosage without consulting the clinician; often coupled with seeking early replacement prescriptions. Associated with continued requests for dose escalations.
  • Seeking opioids from different doctors and other prescribers. This can take place within GP practices, often identifying locum doctors or doctors unfamiliar with their case. This may be associated with attempting unscheduled visits.
  • Obtaining medication from multiple different providers, NHS and private GPs, repeatedly and rapidly deregistering and registering with GPs, seeking treatment for the same condition from both specialists and GP; or seeking treatment from multiple specialists. This may be coupled with a refusal to agree to writing to the main primary care provider.
  • Obtaining medications from the internet or from family members or friends.
  • Resisting referrals to acute specialists about complex physical conditions or failing to attend specialist appointments.
  • Appearing sedated in clinic appointments.
  • Misusing alcohol or using illicit or over-the counter, internet or other prescribed drugs or a past history of alcohol or other drug dependence.
  • Deteriorating social functioning including at work and at home.
  • Resisting or refusing drug screening.
  • Signs or symptoms of injecting opioids or snorting oral formulations.

Assessment

A comprehensive history should be taken from any patient in whom opioid dependence is suspected. It is important to understand the medical indication for which opioids were prescribed initially. As far as possible, confrontation should be avoided, as should judgement about the motivations of the patient. Important points that should be clarified include:

  • Medical indication for opioid.
  • Full list of all medication, routes of administration and how long prescribed.
  • What other medication with addictive potential is prescribed to the patient including benzodiazepines and gabapentin/pregabalin.
  • What the patient perceives as positive and negative attributes of prescribed opioids.
  • Current alcohol and illicit drug use.
  • Current physical health.
  • Current psychological health.
  • Current tobacco consumption.
  • Previous history of drug and alcohol dependence and treatment.
  • Physical health history and any interventions.
  • History of psychiatric illness.
  • Social functioning and employment status.
  • Family and carer support.
  • Appropriate physical examination.

Investigations

  • Urine or other drug screening for prescribed opioid and commonly abused illicit drugs.
  • Consider use of the Objective Opioid Withdrawal Scale (OOWS) and the Subjective Opioid Withdrawal Scale (SOWS) where relevant.
  • Relevant blood tests possibly including full blood count, liver function tests, hepatitis B & C, and HIV.
  • Any other relevant investigations regarding condition for which opioids were initially prescribed.
     

Other sources of information should be sought including:

  • Discuss with other clinicians currently (or previously where relevant) involved in patients care.
  • Clinic letters regarding prescription or underlying diagnosis
  • Information from family or carers

Treatment

Once a diagnosis of dependence has been made a treatment plan should be developed. The decision on which treatment course is chosen should be a collaborative one between the patient and doctor.

Depending on the complexity of the case and the skills and training of the prescriber this may be all under one doctor or it may involve a full network of clinicians, including GPs, addiction specialists, pain specialists, psychiatric specialists and acute services, or some point in between. Clear communication between all healthcare specialists involved in the patient’s care is vital as is clear documentation. It is important to note that many patients will recognise that they have an issue with prescription opioid dependence and will be willing to work in collaboration with their doctor to develop a treatment plan.

Usually one doctor should take over all prescribing of opioids and other potentially addictive drugs. If there is disagreement between the doctor and patient it may be beneficial if a different doctor who has not previously treated the patient takes over prescribing so that a new relationship and set of boundaries can be developed.

Information about the acute and chronic risks of opioids should be given to the patient.

Any underlying physical or psychiatric condition should be identified and appropriate treatment plans or referral made.


Principles of opioid substitution treatment (OST)

If a diagnosis of dependence is made a decision needs to be reached regarding whether to maintain a patient on opioids or detoxify them. This decision involves multiple factors and should be made, where possible, in collaboration with the patient. The decision to maintain a patient versus detoxify can be influenced by factors that include: patient choice, a patient’s motivation, past drug and alcohol dependence, psychiatric and physical history, length of time on opioids, quality of life and social support. It may involve a meeting of multiple healthcare professionals involved in the case. The patient should be provided with as much information as possible so that they can make an informed choice. It may be important to record that the patient has the capacity (within the meaning of the Mental Capacity Act 2005) to make a decision.


Maintenance

If a decision is made to maintain a patient they should generally be transferred to a longer-acting, oral opioid. These include methadone and buprenorphine. Methadone and buprenorphine should be used cautiously in those with a history of respiratory difficulties, significant liver dysfunction and obstructive bowel conditions. Higher dose methadone is associated with prolonged QT syndrome.

Conversion tables should be treated with great caution. Conversion should only be undertaken with the support of a clinician experienced in opioid conversion and the use of methadone or buprenorphine. Advice should be sought from the local drug treatment provider.

It is advisable to consider a period of supervised consumption; however, a patient should not be converted to a fully supervised dose immediately as it places them at risk of overdose if they have been non-compliant.

The same doctor should regularly review the patient; the full range of treatment needs should be reviewed.

Consideration should be given to involving the patient in a wider addiction treatment programme. This may include, as an individual or in a group, motivational enhancement therapy, relapse prevention and/or mutual aid (including Narcotics Anonymous).

The patient should be regularly tested for the prescribed opioid and commonly used illicit substances. They should regularly be asked about alcohol and other drug use.


Detoxification

Detoxification will often be the preferred option. Usually this should take place on an outpatient basis (although residential treatment, either in an acute hospital or detoxification unit, is available throughout the UK). The options involve either conversion to a long-acting opioid as above or a gradual reduction in the dose of the currently prescribed opioid. This reduction should take place in collaboration with the patient.

If a patient chooses to detoxify, they should be warned of the risk of overdose if they relapse to opioid use.

In certain patients who have detoxified and do not need on-going opioids consideration should be given to prescribing naltrexone. 


Naloxone

In those patients considered dependent and at risk of overdose, the provision of take-home naloxone with associated overdose training should be considered for both the patient and their family and carers.

There are risks of naloxone use in the frail and elderly due to increased adrenaline levels after use and it should be supplied (and administered) with caution. Doses should be administered conservatively in all patients.


Role of specialist drug and alcohol dependence treatment services

Every local area in the UK has a specialist addiction service; in England these are commissioned by local authorities, in Scotland and Wales by the NHS and in Northern Ireland by the Public Health Agency. These services should provide advice, assessment and support to other parties involved in the care of this patient group and, where appropriate, take over prescribing of opioids either looking towards detoxification or maintenance. In complicated patients it may be appropriate for these services to become the lead agency. Depending on the area they may be able to provide support regarding co-occurring mental health issues; however, in England psychiatric services are separately commissioned and provided.


Sources of Support

More information in Drug Misuse and Dependence: UK Guidelines on Clinical Management.

 

NHS Choices maintains a searchable directory of local drug and alcohol treatment services.


Further Reading

  • Department of Health Drug Misuse and Dependence: UK Guidelines on Clinical Management. 2007
  • National Institute for Health and Care Excellence. Technology appraisal 114. Methadone and buprenorphine for the management of opioid dependence. 2007.
  • National Institute for Health and Care Excellence. Clinical guideline 52 Drug misuse in over 16s: opioid detoxification. 2007.
  • National Institute for Health and Care Excellence. Technology appraisal 115 Naltrexone for the Management of Opioid Dependence. 2007.
  • Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015; 156: 569–576.