Opioid misuse is a public health crisis in many countries, which has led to a high rate of overdose deaths and addiction. During the COVID-19 pandemic, deaths from accidental overdose increased in Canada by 91 percent from April 2020 to March 2022. 

National prescription drug return programs can reduce and prevent opioid misuse and addiction. Healthcare providers also play a critical role in prevention and effective pain management practices. 

Understanding the Opioid Epidemic 

Since surveillance began in 2016, the rates of opioid addiction and related deaths in Canada have steadily increased. There are a few key factors. 

Causes of Misuse

Opioid medications are important for acute and palliative pain management and sometimes chronic pain. However, these medications have a high potential for misuse because they produce euphoria and are addictive. Certain factors increase the risk.

Overprescribing is a chief factor in misuse and includes high doses and long-term prescribing. Once patients develop a physical dependence, they may also engage in double doctoring. 

These patients switch between doctors, nurses, and pharmacists to get multiple prescriptions or until they find one willing to prescribe opioids. This leads to overprescribing, especially in areas without drug monitoring systems, and to prescription fraud. 

Untreated or poorly managed mental illness is also a factor. Patients may seek out opioids or turn to illicit drugs for euphoria, to improve mood, or to cope with stress. 

Best Practices for Opioid Misuse Prescribing 

As a healthcare provider, you play a critical role in misuse prevention. One of the most important elements is appropriate prescribing practices, from managing pain with other methods to trial dosing and close patient monitoring. 

Current Guidelines

Opioid prescribing guidelines went into effect in Canada in 2017 and outline the best approach to prescribing opioids and at what doses. 

These guidelines apply to non-cancer, chronic pain:

• Manage pain with non-opioid medications or non-drug therapies first. 
• Trial opioids only after you’ve exhausted other methods.
• Do not prescribe to patients with a history of a substance use disorder.
• Do not prescribe to patients with mental illness until stabilized. 
• Restrict dosage to under 90 mg morphine equivalents daily (MED) for patients starting opioids, though under 50 mg MED is highly recommended.
• Encourage patients already taking more than 90 mg MED to start gradual tapering.
• Give clear instructions for medication use and refill policies. 
• Monitor patients closely and adjust as necessary.
• Get informed consent before starting patients on opioids. 

Patient Risk Assessment and Monitoring

Patient risk assessment and monitoring are a constant part of prescribing opioids. Screen for risk factors before starting a patient on a prescription, including:

• History of substance misuse, including alcohol
• Current substance use disorder
• Mental illness
• Cannabis use

Once the patient starts the medication, monitor for signs of misuse, adverse reactions, pain intensity, and changes in functional status. For best results, identify the lowest effective dose. Opioids lose effectiveness for pain relief after three to six months due to tolerance. 

Use PDMP for Diversion Prevention

Electronic databases in a prescription drug monitoring program (PDMP) help pharmacists and clinicians monitor prescriptions and opioid use. E-prescriptions sent directly to pharmacists can prevent fraud and increase patient safety.

Pharmacists must complete an assessment and log it every time a patient fills a new opioid prescription or refills one. These checks and balances reveal red flags about patient misuse. 

Alternative Pain Management Strategies 

Other pain-relief strategies can improve quality of life. A combination of therapies might be helpful, but consider patient income and insurance coverage. Those with low-income status may not have access to some treatments, so this strategy can backfire and encourage them to look for illicit drugs. 

Non-opioid Medications

Non-opioid treatments are the first line of treatment for non-cancer chronic pain. These include:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Acetaminophen
• Anticonvulsants
• Antidepressants
• Topical analgesics like capsaicin

Non-medication therapies may also relieve pain, including:

• Low-level laser therapy
• Massage therapy
• Manual therapy
• Transcutaneous electrical nerve stimulation (TENS)
• Exercise and strength training
• Yoga 

Behavioural Therapies

Behavioural therapies can help patients learn how to cope with pain and reframe thoughts about pain. These therapies can also help patients set goals to add activity at a sustainable pace. 

Behavioural therapies can include:

• Mindfulness training
• Cognitive behavioural therapy
• Acceptance and commitment therapy

Addressing Opioid Addiction and Misuse

Encourage patients with high doses and long-term use to taper medications. If they experience adverse effects, switching opioids can be one way to encourage tapering. Follow up every three days during a switch and weekly during tapering. Referral to rehabilitative services may be necessary.

Awareness of causes, guidelines, and strategies is essential in clinical practice to reduce and prevent opioid misuse and addiction. Join the MDBriefCase community for free and stay up-to-date.