Primary care management of Long-Term opioid therapy

Abstract

The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient's life that influence health outcomes, should be implemented at all points of care.Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised.Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny.Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.

Keywords: Opioids; buprenorphine; chronic pain; naloxone; opioid stewardship; substance use disorder.

Figure 1.

Interventions with evidence of benefit for selected chronic pain conditions [6]. Adapted from the authors’ public domain document “Opioids and Chronic Pain: A guide for primary care clinicians”, San Francisco Department of Public Health, accessed at www.ciaosf.org on 30 November 2021.

Figure 2.

Opioid Management Options. Adapted from the authors’ public domain document “A Guide for Primary Care Providers”, San Francisco Department of Public Health, accessed at www.ciaosf.org on 30 November 2021.

Figure 3.

Simplified opioid metabolic pathways. Adapted from the authors’ public domain document “A Guide for Primary Care Providers”, San Francisco Department of Public Health, accessed at www.ciaosf.org on 30 November 2021. Note: buprenorphine, fentanyl, and methadone all require a separate test.

Figure 4.

Mu opioid receptor activities of medications used for opioid use disorder. (Only the extended-release formulation of naltrexone is approved for for opioid use disorder (specifically for prevention of relapse to opioid dependence)). Figure taken with permission from the authors’ public domain document “A Guide for Primary Care Providers”, San Francisco Department of Public Health, accessed at www.ciaosf.org on 30 November 2021.