Continuing Opioid Therapy

Deciding to continue opioid therapy

Clinicians should always involve patients in decisions about whether to continue opioid therapy, including discussing the benefits and risks of changing the opioid dosage.

Before continuing opioid therapy, ensure patients are aware of the following factors:

• Expected benefits of continuing opioids
• Common risks of opioids
• Serious risks of opioids
• Alternative therapies to opioids

Shared decision-making is important when weighing the benefits and risks of continuing opioid therapy.

If benefits outweigh the risks clinicians should work closely with patients to optimize non-opioid therapies while continuing opioid therapy.

If benefits do not outweigh the risks clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual clinical circumstances of the patient, to appropriately taper and discontinue opioids.

Unless a patient has indications of a life-threatening issue, such as warning signs of impending overdose, opioid therapy should not be discontinued abruptly. Clinicians should carefully weigh both the benefits and risks of continuing opioid medications and the benefits and risks of tapering opioids (Recommendation 5 of the 2022 Clinical Practice Guideline).

Considerations for continuing opioid therapy

Acute Pain (less than 1 month)

• Assess the benefits and risks of opioids at least every 2 weeks.
• Avoid prescribing additional opioids to patients "just in case" pain continues longer than expected.
• Ensure that potentially reversible causes of chronic pain are addressed for patients who started opioid therapy for acute pain and have been treated with opioid therapy for more than 30 days (Recommendation 2).

Subacute Pain (1-3 months) and Chronic Pain (more than 3 months)

• Assess the benefits and risks of opioids within 1 to 4 weeks of starting opioid therapy for subacute pain and at least every 3 months for chronic pain or when increasing dosage.
• Use caution when prescribing opioids at any dosage.
• Reassess the patient's pain, function, and treatment course.
• Evaluate carefully individual benefits and risks when considering increasing dosage.
• Avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients (Recommendation 4).
• Ensure that potentially reversible causes of chronic pain are addressed and that opioid prescribing for acute pain does not unintentionally become long-term opioid therapy simply because medications are continued without reassessment (Recommendation 2).
• Establish treatment goals, including functional goals, for continued opioid therapy for new patients already receiving opioid therapy.
• Avoid rapid tapering or abrupt discontinuation of opioids (Recommendation 5).
• Regularly reassess all patients receiving long-term opioid therapy, including new patients, every 3 months or more frequently if needed. (Recommendation 7).

Patients at Higher Risk for Opioid Use Disorder or Overdose

• Assess the benefits and risks of opioids more frequently than every 3 months. For example, for patients with depression or other mental health conditions, a history of overdose or substance use disorder, those who are taking ≥50 MME/day or who are taking other central nervous system depressants with opioids.
• Clinicians should regularly evaluate risk for opioid-related harms and discuss with patients because conditions can change during the course of treatment (Recommendation 8).

Long-Term Opioid Therapy and Acute Pain Management

For example, if a patient is already receiving long-term opioids and requires additional opioids for severe acute pain (e.g., major surgery).

• Only continue additional opioids for the duration that the acute pain is severe enough to require them.
• Return to the patient's baseline opioid dosage as soon as possible.
• Minimize withdrawal symptoms by tapering to baseline dosage if additional opioids were used continuously for more than a few days.

See Recommendations 4, 5, 6, and 7 for more information on continuing opioid therapy for acute, subacute, or chronic pain.

Follow-up visits

Follow-up is recommended within 1 to 4 weeks of starting opioid therapy for subacute or chronic pain or after increasing dosage (Recommendation 7).

Consider follow-up intervals within 1-2 weeks when:

• Extended-release and long-acting (ER/LA) opioids are started or increased.
• Total daily opioid dosage is at least 50 MME/day.

Patients receiving opioid therapy for chronic pain should receive regular reassessment of benefits and risks. The suggested interval is every 3 months or more frequently depending on the clinical scenario.

During follow up appointments, clinicians should ask patients about their preferences for continuing opioids based on the effects of therapy on pain and function relative to any adverse effects experienced.

Clinicians should determine whether opioids continue to meet treatment goals, including sustained improvement in pain and function.

Clinicians should determine whether the patient has experienced common or serious adverse events or early warning signs of serious adverse events or has signs of opioid use disorder.

Be cautious when treatment for acute pain is longer than 30 days.

Patients who initially received opioid therapy for acute pain and have been treated for more than 30 days should take care to ensure that opioid prescribing does not unintentionally become long-term opioid therapy.

Initiation of long-term opioid therapy should be an intentional decision. The benefits of opioid therapy should outweigh risks, and there should be an informed discussion between clinician and patient as part of a comprehensive pain management approach (Recommendation 2).

For more information on evaluating and discussing a patient's risk for opioid-related harms visit, Assessing risks and potential harm of opioids.

Increasing opioid dosage

Clinicians should carefully evaluate a decision to increase dosage based on individualized assessment of:

• Diagnosis
• Incremental benefits for pain and function relative to risks. (Recommendation 4)
• Other treatments and effectiveness
• Patient values and preferences

Review patient medication history

During long-term opioid therapy, prescription drug monitoring program (PDMP) data should be reviewed at least every 3 months or more frequently (Recommendation 9). Clinicians should use specific PDMP information about medications prescribed to their patient in the context of other clinical information, including their patient's history, physical findings, and other relevant testing, in order to help protect and communicate with their patient. Learn more about PDMP programs.

Toxicology screening

Clinicians should consider the benefits and risks of toxicology screening, such as urine drug screening, to assess for prescribed opioid medications as well as other prescribed and non-prescribed controlled substances. Some substances, such as benzodiazepines and illicit opioids, increase the risk for overdose when combined with opioids.

Before ordering toxicology testing, clinicians should have a plan for responding to unexpected results. Clinicians should explain to patients that the results will not be used punitively (e.g., to dismiss patients from care) and that testing is intended to improve their safety.

Caution: opioids and other central nervous system depressants

Clinicians should use caution when prescribing opioid pain medication and benzodiazepines concurrently. Clinicians should also consider whether the benefits outweigh the risks of concurrent prescribing of opioids and other central nervous system depressants such as:

• Muscle relaxants
• Non-benzodiazepine sedative hypnotics
• Potentially sedating anticonvulsant medications such as gabapentin and pregabalin

Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians and consider involving pharmacists as part of the management team when opioids are co-prescribed with other central nervous system depressants.