Writing an opioid Rx for people on opioid replacement therapy with acute pain
Minimize analgesic abuse potential:
Consider prescribing discharge opioid analgesics with the following modifiers:
• Fax the Rx to the pharmacy they use for their maintenance medication. This prevents the chance of Rx forgery and helps keep their opioid agonist providers aware of the therapy.
• Specify “to be dispensed with methadone or buprenorphine”. The patient will then get more or less analgesics “in hand” depending on their stability. For example a patient with full carries will get 6 days of opioid analgesics to take home whereas a patient with no carries will get their opioids every day when the come to get their maintenance opioids.
• Use a shorter duration of therapy – perhaps 1 week assuming they will be in a condition to get to BMC within this time frame. BMC can take over at that point.
• Prescribe an appropriate dose of analgesic opioids – they will likely have a significantly higher tolerance to opioids than the opioid naive patient. A reasonable starting point is twice the amount of analgesic for an opioid naive patient in the same circumstance – for example 10mg of oxycodone q4h instead of 5mg. This is a group of patients that can access illicit opioids if their analgesic Rx is subtherapeutic. Being exposed to the triggers involved in procurement of illicit opioids is a much higher risk to their recovery than using prescribed opioids to treat their pain. They are less likely to use illicit opioids if their pain is controlled.
• Provide a Rx for adjuvant medication if appropriate.