Module 2: Basic Pharmacology of Controlled Drugs and Substances

Lesson 1

Opioids – General approaches to management

Because of their psychoactive effects, opioids pose a particular set of challenges to patients and prescribers. It is important, therefore, to keep the following general principles in mind when planning an approach to opioid prescription (NOUGG, 2017):

  • Initiating therapy with any opioid must be considered to be a trial that should be discontinued if desired outcomes are not achieved.
  • Patient expectations must be managed realistically; there needs to be an open discussion that improved function may be a better benchmark of success than a total resolution of pain symptoms which may not be achieved.
  • The dose of the opioid should not be increased if the pain is well controlled and/or functionality improves.
  • Non-opioid or non-pharmacologic analgesics or adjuvant agents must be optimized before adding an opioid as a trial (e.g. NSAID for musculoskeletal pain, gabapentinoid for post herpetic neuralgia).
  • Referral for alternative therapies, such as regional anesthetic injections, surgical interventions, massage, and acupuncture should be considered.
  • A switch in the type of opioid prescribed or in the route of administration may provide a better balance of analgesia vs. adverse effects.
  • Adverse effects must be anticipated and managed.