Risk Reduction for Opioid Prescribing Guide
Primary Care
(Adapted from University of Rochester Strong Memorial Hospital 2024 PolicyStat guidelines)
Purpose
This guide was developed for clinicians in the outpatient setting to help promote safe opioid use.
Main points
Opioid prescribing principles
Transitioning full agonist opioid to buprenorphine
Opioid tapering strategies
Safety and monitoring including withdrawal symptoms
Rural considerations
This guide was developed to support rural primary care clinicians as they manage their patients’ complex chronic pain, which may include opioid prescriptions. It was developed in response to a direct request from a primary care practice our center is partnering with in rural New York State. The practice expressed interest in information about safe use of opioids in the management of chronic pain.
Please consider the following suggestions in addition to consulting this guide:
If feasible, partner with a larger medical center/hospital system to assist with complicated cases and/or a pain management specialist like a palliative care provider who will be available to answer specific questions.
Develop consistent protocols for all controlled substance medications, especially for ordering, monitoring, clinical documentation, and intervention parameters. This will help establish clear expectations for all patients and providers.
Utilize telehealth communication platforms to assist patients with transportation barriers.
Co-prescribe naloxone routinely for patients at high risk for opioid overdose, and offer to all patients who are prescribed opioids.
Avoid benzodiazepine-opioid combinations whenever possible.
Join a Project ECHO hub for pain management and behavioral health support.
Develop informal case-review groups with nearby clinicians.
Resources:
Substance Abuse and Mental Health Services Administration (SAMHSA) for rural grants and medications for opioid use disorder (MOUD) resources
Health Resources and Services Administration (HRSA) Rural Communities Opioid Response Program (RCORP) for grants and opportunities to collaborate with outside health centers
American Society of Addiction Medicine (ASAM) for clinical guidance
Providers Clinical Support System (PCSS) for free addiction training
Opioid indications
Opioids should only be prescribed after clinical examination, diagnosis, pain and risk assessment, consideration of non-opioid/non-pharmacologic options, and review of the state prescription monitoring program (such as I-STOP in New York).
Screen for personal or family history of substance use disorder (SUD)/mental health disorder and preadolescent sexual abuse using the Opioid Risk Tool. These risk factors aren't absolute contraindications to the safe use of opioids but simply indicate that caution and more frequent monitoring may be clinically appropriate.
Screen for high-risk factors for opioid-related adverse events, such as a history of overdose.
Opioid prescribing principles
If opioids are necessary, they should be ordered/prescribed at the lowest effective dose for the shortest duration needed.
For acute pain unrelated to major surgery/trauma, no more than a 7-day supply should be prescribed (3 days should be considered the standard whenever possible).
Longer opioid courses or higher pill quantities should not be prescribed more than the expected or observed need to avoid refill requests.
Lost/stolen/missing opioids should not be routinely refilled.
Increased opioid doses are associated with opioid-related morbidity and mortality.
Whenever possible, concurrent use of opioids and benzodiazepines should be avoided, and careful consideration should be used with opioids and other central nervous system (CNS) depressants (e.g., muscle relaxants or sleep aids).
If prescribing opioids and benzodiazepines is necessary, also offer and prescribe naloxone, emphasizing the risks to patient for unintentional overdose.
Long-acting or extended-release opioid products should not be used for acute pain.
Combination opioid/acetaminophen preparations should be avoided. Acetaminophen in a separate dosage form should be optimized when clinically appropriate.
Oral opioids are preferred over intravenous (IV) if clinically appropriate.
If applicable, opioids prescribed after hospital discharge should reflect actual administration requirements.
Tapering plans should be discussed with the patient before hospital discharge and with clinicians coordinating the patient’s care as an outpatient.
Routine monitoring
All patients should have a valid and up-to-date controlled substance agreement with their provider.
Continue the tapering process: Tapering should be unidirectional.
If the patient is experiencing significant pain or withdrawal symptoms when they are scheduled to have another dose decrease, extend the taper by 1 week.
Avoid returning to prior doses unless deemed necessary for pain relief.
Extending time between dose decreases may also be considered if a patient is not emotionally ready to reduce a dose but has been making reasonable effort to adhere to the taper.
Patients should receive appropriate psychosocial support. Watch for signs and symptoms of anxiety, depression, and opioid use disorder (OUD) during the taper. Make referrals as needed.
Urine toxicology screens should be performed at least yearly.
Review the state prescription monitoring program at least every 3 months.
Patients meeting high-risk criteria should be prescribed and educated on the use of naloxone.
Collaborate with a clinical pharmacist to assist with designing opioid taper schedules.
Consult/coordinate with specialists and treatment experts (especially for patients at higher risk of harm from opioid tapers such as those who are pregnant).
Naloxone prescribing
Offer a naloxone prescription to anyone meeting high-risk criteria for adverse events and allow patients to opt out.
Any prescribing clinician or nurse can identify patients by reviewing the problem list, admitting diagnosis, and medication list to determine if the patient meets high-risk criteria.
Prescribing naloxone is safe and unlikely to result in harm; therefore, a low threshold for prescribing should be used. Consider offering naloxone to any patient on opioids.
High-risk criteria include:
Receiving an opioid prescription and:
≥ 50 morphine milligram equivalent (MME) per day
Benzodiazepines, barbiturates, or other sedatives (including muscle relaxers)
Respiratory conditions (e.g., COPD, obstructive sleep apnea)
Heavy alcohol use
Other special considerations that lead to opioid accumulation or risk of opioid adverse effect: advanced age (> 65 years old), renal dysfunction (CrCL < 30 mL/min), or cirrhosis
History of OUD/SUD or concern for misuse
History of IV drug use
Receiving care for opioid intoxication or overdose
Receiving MOUD (e.g., buprenorphine/naloxone or methadone)
Reduced tolerance from prolonged period of abstinence or dose reduction (e.g., being released from prison, detoxification facility, or hospital)
Difficulty accessing emergency medical services due to distance or remoteness
Voluntary request from patient or caregiver
Naloxone prescribing recommendations
Outpatient clinic prescribing | Patients should be notified of the plan for naloxone prescription. Prescription should be sent to an outpatient pharmacy: naloxone (Narcan) nasal spray 4 mg/0.1 mL |
Education | Patient/caregiver training:
|
Provider liability | Most U.S. states have enacted laws (i.e., Good Samaritan, naloxone access laws) that protect providers from civil or criminal liability when prescribing or dispensing naloxone in good faith. Please refer to your state-specific public health laws for guidance. |
Equianalgesic dosing and morphine milligram equivalent (MME) conversions
When converting from one opioid to another, it is recommended to decrease the dose of the new opioid by 25% to 50% to avoid overdose due to incomplete cross-tolerance and individual variability in opioid pharmacokinetics.
Opioid | Conversion Factor | 50 MME Dose |
Codeine | 0.15 | 50 mg morphine / (0.15) ~ 333.33 mg codeine |
Fentanyl transdermal (mcg/hr) | 2.4 | 50 mg morphine / (2.4) ~ 20.83 mcg/hr fentanyl |
Hydrocodone | 1.0 | 50 mg morphine / (1.0) = 50 mg hydrocodone |
Hydromorphone | 5.0 | 50 mg morphine/ (5.0) = 10 mg hydromorphone |
Morphine | 1.0 | 50 mg morphine/ (1.0) = 50 mg morphine |
Oxycodone | 1.5 | 50 mg morphine / (1.5) ~ 33.33 mg oxycodone |
Tapentadol † | 0.4 | 50 mg morphine/ (0.4) = 125 mg tapentadol |
Tramadol § | 0.2 | 50 mg morphine / (0.2) = 250 mg tramadol |
Equianalgesic dose conversions are only estimates and cannot account for individual variability in genetics and pharmacokinetics.
When converting opioids, the new opioid is dosed at a substantially lower dose than the calculated MME amount to avoid overdose because of incomplete cross-tolerance and individual variability in opioid pharmacokinetics. (Generally, the dose is reduced by 25–50% after conversion.)
Methadone has been excluded above due to varying dosing guidelines and its long and unpredictable half-life. The conversion factor increases as the dose increases. If you do not have experience dosing methadone, it is recommended to reach out to a pharmacist or pain management specialist for assistance.
† Tapentadol is a µ-receptor agonist and norepinephrine reuptake inhibitor, and tramadol is a µ-receptor agonist and norepinephrine and serotonin reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tapentadol or tramadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists.
§ Tramadol is a µ-receptor agonist and norepinephrine and serotonin reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tramadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists.
Equianalgesic calculator
To calculate equivalent dosing between opioids that are not morphine an equianalgesic calculator may be used.
Transitioning to buprenorphine for chronic pain
Currently, there is no Centers for Disease Control and Prevention (CDC)-accepted conversion for buprenorphine to MME for patients with high degrees of opioid tolerance. Manufacturer recommendations for conversions are offered below:
Buprenorphine buccal film (Belbuca)
(Approved by the U.S. Food and Drug Administration (FDA) for chronic pain management)
Determine the appropriate buprenorphine buccal film starting dose based on the patient’s total daily opioid dose prior to taper.
Titration shouldn’t occur more frequently than every 4 days, with doses in every 12-hour intervals.
After initiation, proceed with individual titration in increments of 150 mcg.
In patients with severe hepatic impairment or with known or suspected mucositis, reduce starting and titration dose by half that of patients with normal liver function or without mucositis.
Opioid naive dosing:
Initial: 75 mcg once daily, or if tolerated every 12 hours for ≥ 4 days, then increase to 150 mcg every 12 hours
Opioid-experienced patients (conversion from other opioids to buprenorphine):
Discontinue all other around-the-clock opioids when buprenorphine is initiated. Taper patient's current opioid to no more than 30 mg oral MME daily before initiating buprenorphine. Following analgesic taper, base the initial buprenorphine dose on the patient's daily opioid dose prior to taper. Patients may require additional short-acting analgesics during the taper period.
Patients who were receiving daily dose of < 30 mg of oral MME:
Initial: buprenorphine 75 mcg once daily or every 12 hours
Patients who were receiving daily dose of 30 to 89 mg of oral MME:
Initial: buprenorphine 150 mcg every 12 hours
Patients who were receiving daily dose of 90 to 160 mg of oral MME:
Initial: buprenorphine 300 mcg every 12 hours
Patients who were receiving daily dose of > 160 mg of oral MME:
Buprenorphine buccal film may not provide adequate analgesia; consider the use of an alternate analgesic.
Maximum dose is 900 mcg every 12 hours. Do not exceed due to the potential for QTc interval prolongation. If pain is not managed at this maximum dose, or for patients previously taking > 160mg oral MME, consider an alternative analgesic.
For additional information visit the manufacturer website: https://www.belbuca.com/hcp/buprenorphine-dosing-titration
Buprenorphine patch/transdermal system (Butrans)
(FDA approved for chronic pain management)
Determine the appropriate buprenorphine patch starting dose based on the patient’s total daily opioid dose prior to taper.
Opioid-naive patients:
Initial: 5 mcg/hour applied once every 7 days
Opioid-experienced patients (conversion from other opioids to buprenorphine):
Discontinue all other around-the-clock opioid drugs when buprenorphine therapy is initiated. Short-acting analgesics as needed may be continued until analgesia with transdermal buprenorphine is attained. There is potential for buprenorphine to precipitate withdrawal in patients already receiving opioids.
Patients who were receiving daily dose of < 30 mg of oral MME:
Initial: buprenorphine 5 mcg/hour patch applied once every 7 days
Patients who were receiving daily dose of 30 to 80 mg of oral MME:
Taper the current around-the-clock opioid for up to 7 days to ≤ 30 mg/day of oral morphine or equivalent before initiating therapy.
Initial: buprenorphine 10 mcg/hour patch applied once every 7 days
Patients who were receiving a daily dose of > 80 mg of oral MME:
Buprenorphine transdermal patch, even at the maximum dose of 20 mcg/hour applied once every 7 days, may not provide adequate analgesia; consider the use of an alternative analgesic.
Dose titration (opioid-naive or opioid-experienced patients): May increase dose in 5 mcg/hour, 7.5 mcg/hour, or 10 mcg/hour increments (using no more than two patches), based on patient's supplemental short-acting analgesic requirements, with a minimum titration interval of 72 hours (maximum dose: 20 mcg/hour applied once every 7 days; risk for QTc prolongation increases with doses > 20 mcg/hour patch).
Individually titrate buprenorphine patch to a dose that provides adequate analgesia and minimizes adverse reactions. Continually reevaluate patients receiving buprenorphine patch to assess the maintenance of pain control, signs and symptoms of opioid withdrawal and other adverse reactions, as well as reassess for the development of addiction or misuse.
For additional information visit the manufacturer website: https://butrans.com/
Buprenorphine and naloxone sublingual film (Suboxone)
Suboxone is the only formulation of buprenorphine approved by the FDA for the treatment of OUD. However, it is commonly used off label for pain management due to the increased dosing availability.
There is no CDC-accepted conversion for buprenorphine to MME for patients with high degrees of opioid tolerance.
Please consult with treatment experts including pain management specialists, palliative care, or clinical pharmacy for further guidance.
Tapering opioids
Identify goal of taper
Dose reduction to lower (safer) doses
Discontinuation of opioid therapy: Clinicians are justified in discontinuing opioids if: there is evidence of harm, risks are not outweighed by clinical benefit, functional treatment goals are not being met, or high-level of concern for non-adherence to mutually agreed upon treatment.
Considerations to taper opioids
Information in the following table applies to outpatients who are adults or adolescents with chronic, non-cancer pain.
If… | Examples | Plan |
Risk is perceived |
|
|
Evidence of harm |
|
|
Non-adherence to treatment plan / unsafe behavior |
|
|
Lack of clear benefit / not meeting functional goals |
|
|
Patient requests to discontinue / reduce dose |
|
|
Concern about SUD |
|
|
Concern for diversion |
|
|
Opioid taper tips
Several factors may impact the rate of taper:
Urgency to discontinue therapy (e.g., misuse, diversion, risk of continuing outweighs harm of a rapid taper)
Duration of previous opioid therapy
Total daily MME
Dose and frequency changes should be considered in collaboration with the patient to meet goal percent decrease at varying points in the taper.
Tapers may be accomplished by reducing the dose, extending the dosing frequency, and/or converting to a single long-acting agent.
Pauses in the taper may be necessary and allow the patient time to acquire new skills for management of pain and emotional distress while allowing for neurobiological equilibration.
Avoid increasing the dose once the taper has begun.
Rationale and taper schedule should be documented in the medical record.
General concepts for designing opioid tapers
Considerations | Approach |
Which medications to taper first? |
|
Desired rate of taper | Factors impacting the rate of taper should include:
|
Slow taper (months to years) — most common |
|
Faster taper (over weeks) | Reduce by 10%–20% every week. |
Rapid taper (over days) | Reduce by 20%–50% of first dose, then reduce by 10%–20% every day. |
Reducing the dose vs. extending the dosing frequency | Patients who are used to taking multiple short-acting agents daily may prefer reductions in dose to reductions in frequency.
|
Selecting long acting vs. combination of agents to taper with |
|
When to stop | Once the smallest available dose is reached, the interval between doses can be extended and you can stop once frequency of dosing is less than once daily. |
What to discuss with patients and/or caregivers
Taper
Risks of continued use, along with possible benefits; partner with the patient to establish a plan.
Provide clear written and verbal instructions with a schedule for tapers.
Consider writing prescriptions for a 1- to 2-week supply.
When tapering, pain and functional status may initially decline but should stabilize.
Available support during the taper process for safety and tolerance
Risk of withdrawal
Signs and symptoms of opioid withdrawal and a contingency plan
For example, "If you have stomach cramps, anxiety, sweating, diarrhea, dilated pupils, goose bumps, trouble sleeping, twitching muscles, runny nose, etc.), contact the office. These reactions are typically not dangerous but can be uncomfortable. We can work to slow or pause your opioid taper as needed and/or prescribe other medications to lessen your discomfort."
Risk of overdose
Strongly caution patients that opioid tolerance diminishes quickly and they are at risk for overdose if they resume prior doses, particularly if they have access to remaining supplies in the home, from family/friends, or illicit sources or heroin.
Prescribe naloxone for overdose prevention and provide opioid overdose education if at increased risk.
Treatment of withdrawal during a taper
Fast and rapid tapers have the highest likelihood of withdrawal.
Consider admitting for detox/inpatient care to manage withdrawal.
Do NOT reverse the taper; the rate may be slowed or paused while monitoring or managing withdrawal symptoms.
Symptoms of withdrawal
Early symptoms (hours to days) | Late symptoms (days to weeks) | Prolonged symptoms (weeks to months) |
|
|
|
Management options
- 1.Provide prescriptions for symptomatic management.
- 2.Offer buprenorphine induction
- a.Belbuca, Butrans for MME < 80 (if not covered by insurance can cut 2 mg/0.5 mg Suboxone films into small pieces)
- b.Suboxone for MME >80 and/or concurrent illicit opioid use
- a.
- 3.Refer patient to SUD evaluation if non-prescribed opioids are being used or other substances.
Buprenorphine inductions with Suboxone
Consideration | Recommendations |
Opioid washout | For a traditional induction the period of time recommended without use of respective full agonist to avoid buprenorphine precipitation of a withdrawal reaction (displaces full opioid agonists from mu-receptor) Recommended opioid abstinence time:
Consider consultation with addiction medicine, pain management or palliative care clinician for washout period questions in challenging cases (e.g., high doses of long-acting opioids). |
Patient instructions | Buprenorphine/naloxone administration:
Patients using illicit opioids may benefit from follow up with an SUD treatment program. |
Low dose induction Start with very low doses of buprenorphine. Do not hold other opioids or wait for obvious signs or symptoms of withdrawal. The microdose induction tends to be more acceptable for patients as it does not require them to go into withdrawal before starting the buprenorphine. | 1 mg bioavailable buprenorphine ~ 75 mg oral morphine Patients continue their prescribed or illicit full agonist opioids until buprenorphine is built up in their system. For less than 80 MME: Option 1 (if Belbuca is covered) Day 1: Start Belbuca once/day 150 mcg (1/2 of the 300 mcg film). Continue full agonist opioid. Day 2: Belbuca 300 mcg once/day Continue full agonist opioid. Day 3: Belbuca 300 mcg BID STOP FULL OPIOID AGONIST. Option 2 (if Belbuca is not covered) Day 1: 0.25 mg buprenorphine once/day (1/8 of a 2 mg film) Day 2: 0.25 mg buprenorphine twice/day (1/8 of 2 mg film in AM and PM) Day 3: 0.25 mg buprenorphine in AM and 0.25 mg buprenorphine in PM (1/8 of 2 mg film in AM and 1/8 of 2 mg film in PM) STOP FULL OPIOID AGONIST. An additional 0.25 mg buprenorphine film PRN can be offered if needed. For patients on MME between 80 and 100: Day 1: 0.25 mg buprenorphine once/day (1/8 of a 2 mg film) Day 2: 0.25 mg buprenorphine twice/day (1/8 of 2 mg film in AM and PM) Day 3: 0.25 mg buprenorphine in AM and 0.5 mg in PM (1/8 of 2 mg film in AM and 1/4 of 2 mg film in PM) Day 4: 0.5 mg in AM and 0.5 mg in PM (1/4 of 2 mg film in AM and PM) Day 5: STOP FULL OPIOID AGONIST For patients on MME between 100 and 140: Day 1: 0.5 mg once/day (1/4 of a 2 mg film) Day 2: 0.5 mg twice/day (1/4 of 2 mg film in AM and PM) Day 3: 0.5 mg in AM and 1 mg in PM (1/4 of 2 mg film in AM and 1/2 of 2 mg film in PM) Day 4: 1 mg in AM and 1 mg in PM (1/2 of 2 mg film in AM and PM) Day 5: no oxycodone; 1 mg in AM and 1 mg in PM Final buprenorphine dose can be titrated up as needed depending on pain levels once transition has occurred. |
Traditional induction |
|
Maintenance | Typical maintenance dose for patients with OUD or using fentanyl or high dose illicit opioids: buprenorphine/naloxone 16/4 mg in one or two divided doses (maximum dose buprenorphine 24 mg per day) Typical maintenance dose for patients switching to buprenorphine for chronic pain from prescribed opioids: 1–2 mg BID Consider lower maintenance dose if any somnolence/lethargy. |
Supportive medications
Concern | Recommendation | |
Pain |
| |
Anxiety |
| |
Nausea | Ondansetron 4 mg oral every 6 hours PRN nausea | |
Diarrhea | Loperamide 2 mg three times daily PRN diarrhea | |
Sleep |
|
Authors
Marin Valentino, PharmD, BCCCP, CPP
References
Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain – United States, 2022. Morbidity and Mortality Weekly Report. Recommendations and Reports, 71(3), 1–95. (See Morphine milligram equivalent doses for commonly prescribed opioids for pain management [Table], https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#T1_down.)
Frady, S., Holtsman, M., & Cutler, E. (2015). Validating the oral morphine equivalents of sublingual buprenorphine [Abstract]. Pain Medicine, 16(3), 609–610. https://academic.oup.com/painmedicine/article/16/3/558/2460644
Society of Hospital Medicine. (2015). Reducing adverse drug events related to opioids Implementation guide. https://www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/shm_reducingopiodevents_guide.pdf
University of Rochester Strong Memorial Hospital. (2024, October 10). Naloxone prescribing guideline [PolicyStat guideline].
University of Rochester Strong Memorial Hospital. (2024, October 10). Opioid tapering guideline [PolicyStat guideline].
University of Rochester Strong Memorial Hospital. (2024, October 10). Pain management and opioid prescribing guideline (expanded) [PolicyStat guideline].
University of Rochester Strong Memorial Hospital. (2023, December 11). URMC morphine milligram Equivalents (MME) or morphine equivalent dose (MED) reference [PolicyStat guideline].
U.S. Department of Health and Human Services. (2019, May). Pain management best practices inter-agency task force report: Updates, gaps, inconsistencies, and recommendations. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
U.S. Department of Veterans Affairs. (2024, March). Buprenorphine for the management of chronic pain: National guidance document. https://www.va.gov/formularyadvisor/DOC_PDF/CRE_Buprenorphine_for_Chronic_Pain_MAR_2024.pdf.
U.S. Food and Drug Administration. (2015, October). [Belbuca label]. Retrieved December 3, 2024, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/207932s000lbl.pdf
U.S. Food and Drug Administration. (2014, June). [Butrans label]. Retrieved December 3, 2024, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/021306s015s019lbl.pdf
