Prescribing opioids in primary care: Safely starting, monitoring, and stopping

Article Figures & Data

TABLE 1

Initiating chronic opioid therapy: recommended steps

Step	Details
Express empathy, partner with your patient	Empathy signals that the provider has the patient’s best interests in mind Expressing empathy does not commit the provider to prescribing opioid therapy
Optimize nonopioid therapy	Utilize nonpharmacologic treatments, adequately dose nonopioid analgesics, and use disease-modifying therapy when appropriate, typically in combination
Frame the treatment plan as a therapeutic trial	Opioids should only be continued: If safe and effective At the lowest effective dose, and As one component of a multimodal pain treatment plan
Target functional goals	Treatment goals should be based on functional improvement, not pain reduction A useful mnemonic to help identify such goals is SMART: specific, measurable, action-oriented, realistic, and time-bound
Obtain informed consent, document thoroughly	Communicate risks, potential benefits, and safe medication-taking practices, including safe storage and disposal of unused opioids Document this conversation clearly in the medical record
Employ safe, rational pharmacotherapy	Consider opioid potency, onset of action, and half-life when choosing a medication Comorbid conditions and concurrent prescriptions should affect choice of formulation, dosage, and rapidity of titration Methadone accumulates in adipose tissue and needs to be up-titrated slowly

TABLE 2

Characteristics of substances on screening immunoassays

Substance	How it appears on standard urine toxicology screening	How long it remains detectable after use^a	Sources of false positivity^b
Amphetamine	Amphetamine	2-3 days (occasional use) 1 week (very heavy use)	Bupropion Ephedrine Vicks Vapor Inhaler^c
Barbiturate	Barbiturate	Short-acting: 1-3 days Long acting: 2-3 weeks	Ibuprofen Naproxen
Benzodiazepine	Benzodiazepine	2-3 days	Efavirenz Sertraline
Buprenorphine	Usually requires separate assay	1-3 days	Amisulpride (rare) Tramadol
Cannabis	Cannabinoid	3-4 days (occasional use) 7-10 days (regular use) 4+ weeks (heavy use)	Efavirenz
Cocaine	Cocaine	2-3 days (occasional use) 3 weeks (heavy use)	Topical anesthetics containing cocaine
Methadone	Methadone	2-3 days	Quetiapine
Codeine Hydrocodone Hydromorphone Morphine	Opiate	2-3 days	Heroin Levofloxacin Other opiates Ofloxacin Oxycodone
Oxycodone	Oxycodone	2-3 days	Naloxone
Phencyclidine (PCP)	Phencyclidine (PCP)	2-3 days (occasional use) 1 week (very heavy use)	Tramadol Venlafaxine

↵a Duration of detection varies with dose taken, frequency of use, and individual metabolism.
↵b Gas chromatography-mass spectrometry is needed to distinguish; false-positives vary by specific assay used.
↵c Vicks Vapor inhaler contains levomethamphetamine, which is the L-entaniomer of methamphetamine. Although the L isomer has no addictive potential or central nervous system effects, repeated use may result in a positive urine drug screen.
Compiled from information in references 1–3, 37–49.

TABLE 3

Discontinuing opioids: Do’s and don’ts

Do	Don’t
Frame the discussion in terms of safety and efficacy, consistent with the treatment agreement Present your reasoning in a considered manner Focus on the treatment and the patient’s response to it Emphasize your commitment to the patient’s well-being and details of the new treatment plan (ie, nonabandonment) Respond to emotional distress with empathy	Debate your decision with the patient Use accusatory or blaming language Focus on the patient’s character or use labels (eg, “drug addict”) Abandon the patient Allow empathy to change your decision on discontinuation