1. META:PHI in Primary Care: Implementing Best Practices for Addictions
Safe Opioid Prescribing

2. What is META:PHI?
Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration
Collaborative project to implement integrated care pathways for addiction throughout Ontario
Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies
Goals:
Improve care for patients with addictions
Improve care provider experience
Improve population health
Reduce service use
Provide sustainable care

3. How it works
Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment
RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed
Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required)
Key components:
Integration of care at hospital, RAAM clinic, primary care
Training, support, and mentorship from addictions specialists
Capacity-building

4. Role of PCPs With support from META:PHI team:
Follow best practices for prescribing opioids
Screen and diagnose patients for substance use disorders
Refer patients to treatment at RAAM clinic when necessary
Take over long-term addiction care for patients (with ongoing support from RAAM clinic doctor)

5. Practice goals for managing patients’ opioid use

6. Practice goals
Only prescribe to patients for whom opioids are likely to be safe and effective.
Always begin therapy with weak opioids.
When prescribing potent opioids, start with a low dose and titrate slowly.
Routinely monitor patients on opioid medications to ensure that they are experiencing meaningful benefit.
Provide patients with education on safely storing medication, preventing overdose, and the risks of sharing opioids with others.
Initiate appropriate treatment or facilitate referral for patients with an opioid use disorder.

7. Opioids for acute pain

8. Opioid treatment for acute pain
Indications
Moderate to severe pain that has not responded to an adequate trial of evidence-based non-opioid treatments (acetaminophen, SNRIs, NSAIDs, physiotherapy)
Contraindications
Mild pain (e.g., low pack pain, dental pain, muscle strains)
Active substance use disorder

9. Protocol for prescribing
Use lowest effective dose
Immediate-release formulation, ideally combined with a non-opioid medication (e.g., codeine + acetaminophen)
Prescribe only enough to last for expected duration of severe pain
Usually 3 days or less
Never more than 7 days

10. Initiating opioid therapy for chronic non-cancer pain

11. Considering an opioid trial
Indications:
Patient has well-defined pain condition (nociceptive or neuropathic) that…
Has been shown to respond to opioids
Causes both pain and disability
Non-opioid treatments are ineffective, contraindicated, or have intolerable side effects
Precautions:
Patient has current, active psychiatric disorder
Contraindications:
Patient has current, recent, or severe past history of substance use disorder (alcohol, opioids, cannabis, etc.)

12. Prior to prescribing opioids (1)
Ask about current/past use of alcohol and drugs
Ask about mood
Patients with depression tend to have heightened perception of pain and may be less responsive to opioids
Check renal/respiratory status, especially risk of sleep apnea
Assess risk of falls
Consider tapering benzodiazepines
Ask about impact of pain on activities of daily living
Rate pain on 0–10 scale (at rest and with activity)

13. Prior to prescribing opioids (2)
Reassess response to non-opioid treatments:
Nociceptive pain: acetaminophen, NSAIDs, SNRIs
Neuropathic pain: anticonvulsants, SNRIs, TCAs
All pain: Mindfulness programs, graded exercise
Inform patient that opioid therapy will be a trial, to be discontinued if side effects outweigh benefits
Advise patients not to drink alcohol during titration
Warn patients to avoid driving for at least two hours after a dose in the first 1–2 weeks of treatment initiation and the first week of dose increase
Warn patients to keep their opioids securely stored and not to give any to anyone else

14. Office visits See patient frequently during initiation and titration
At each visit, ask about changes in:
Work, school, social activities, daily activities
Pain ratings (0–10) at rest and with activity
Mood
Ask about side effects
Sedation, dizziness, other CNS effects
Constipation, nausea

15. Prescribing protocol

16. IR vs. CR Initiate opioid trial with IR preparations
Maintain on IR for brief (< 4 hours) or incident pain
For constant pain throughout the day, switch to CR
In long-term therapy for constant pain throughout the day, IR medications for breakthrough pain should not exceed 10–30% of total daily dose

17. Opioid selection
Initiate with weak opioids: oral codeine, tramadol, or buprenorphine patch
If insufficient analgesia, switch to morphine, oxycodone, or hydromorphone
Morphine contraindicated in patients with renal insufficiency
Some evidence that hydromorphone and oxycodone have fewer cognitive effects in the elderly than morphine
Use extreme caution when prescribing transdermal fentanyl
Contraindicated in elderly patients and patients at risk for opioid use disorder
Use only if patient has taken at least 60–100 mg MEQ daily for at least 2 weeks

18. Initiation and titration
Opioid
Max initial dose
Max dose increase
Min days between increases
Min IR dose before CR
Codeine
200 mg/d
50 mg/d
7 days IR
14 days CR
150 mg
Transdermal buprenorphine
5 μg/7d
7 days
Morphine
40 mg/d
10 mg/d
30 mg
Oxycodone
30 mg/d
5 mg/d IR
10 mg/d CR
20 mg
Hydromorphone
8 mg/d
1–2 mg/d IR
2–4 mg/d CR
6 mg
Tapentadol*
150 mg/d
50 mg/d IR
50 mg/d CR
100 mg
*Maximum CR dose 250 mg bid. Exert caution when switching from pure mu-opioids.

19. Morphine equivalency Opioid Approximate equivalence value
Morphine (reference)
30 mg
Codeine
200 mg
Oxycodone
20 mg
Hydromorphone
6 mg
Tapentadol
100 mg
Transdermal buprenorphine
No equivalence to morphine established
Transdermal fentanyl
25 μg/hr = 60–134 mg oral morphine/day

20. Optimal dose
Effective opioid therapy causes gradual improvement in pain/function as dose increases
Optimal dose reached if:
Pain relief at least 2 points on 10-point scale, with no additional benefit from 1–2 additional increases
Improved functioning at work, school, and with family; increased physical activities
No major side effects
Most patients respond to a dose of 50 mg MEQ or less
Doses above 90 mg MEQ are rarely needed

21. Ongoing vigilance
Opioids have dose-related complications (overdose, sleep apnea, falls/fractures, etc.)
Patients with ongoing prescriptions of 40 mg MEQ or more should have monthly visits to asses:
Pain levels (at rest and with activity)
Function (mood, activities of daily living)
Adverse effects
At doses of 90+ mg MEQ, reassess analgesic effectiveness and side effects
Consider tapering for patients who are receiving insufficient analgesia and/or suffering from opioid-related complications

22. Minimizing adverse effects of opioid therapy

23. Patients at risk of falls
Do not prescribe opioids to cognitively impaired patients unless dispensed and overseen by caregiver
Taper benzodiazepines
Benzodiazepines increase risk and severity of opioid-induced fatigue, sedation, inattention, and overdose
Avoid use of opioids at night if possible
If pain wakes patient up, prescribe small IR dose and warn patient to take extra precautions when getting out of bed

24. Sedation during initiation or dose increase
Inform patient and family of signs of impending overdose
Sedation, slowed speech, nodding off
Patient may appear relatively alert in conversation but have respiratory arrest at night while asleep
Family members should call emergency services at the first sign of an overdose

25. Fatigue
Opioids can cause fatigue either through direct sedating effect or contributing to sleep apnea
If patient reports daytime fatigue or reduced function:
Assess for sleep apnea
Consider reducing or switching opioid

26. Constipation Increase fibre, fluid, activity Consider laxatives:
Polyethylene glycol most effective for opioid-induced constipation
Sodium picosulphate or lactulose may also be effective

27. Opioid switching and tapering

28. Indications for switching
Inadequate analgesic response (pain relief < 2/10, no improvement in function) to current opioid despite reasonable dose
Adverse effects with current opioid (e.g., constipation, sedation)

29. Switching protocol Start with 50% of MEQ of original opioid
Patient will not be fully tolerant to new opioid
Example: When switching a patient from 40 mg/d of oxycodone to hydromorphone…
40 mg/d oxycodone = 60 mg MEQ
60 mg MEQ = 12 mg/d hydromorphone
50% of hydromorphone 12 mg = 6 mg
Therefore, start patient on 6 mg/d in divided doses
Tell patient that taking extra doses is dangerous

30. Why taper?
Tapering after a failed opioid trial often improves patient’s pain, mood, and functioning
Abrupt cessation is very dangerous
Will trigger severe withdrawal
Patient will lose tolerance, increasing risk of overdose
Patient may seek illicit sources of opioids to relieve their withdrawal symptoms (danger of accidental exposure to fentanyl)

31. Indications for tapering
Patient has persistent severe pain and pain-related disability despite adequate dose, and has already failed on a trial of at least one opioid previously
Patient is on an unusually high dose for pain condition
Patient has a complication from opioid therapy
Patient has suspected opioid use disorder, and opioid maintenance therapy with methadone or buprenorphine/ naloxone is not an option

32. Reluctance to taper
Patient may worry that tapering will make their pain worse
Explain why you are tapering:
“I am lowering your opioid dose to prevent future harms and improve your mood and well-being.”
“Tapering is actually likely to improve your pain; opioids often stop working after many months or years, and they can lower your pain threshold, making your pain worse.”
“We’re not necessarily going to stop your opioid; we’re going to lower it to a dose that improves your mood and functioning while keeping your pain manageable.”
“We’ll do this gradually, and I’ll keep checking in to see how you’re doing.”

33. Tapering protocol Formulation CR preferred (until low dose reached)
Dosing interval
Scheduled rather than PRN
Keep dosing interval the same for as long as possible (bid or tid)
Advise patients not to skip doses
Rate of taper
Taper slowly, typically 10% of total daily dose at each visit
No more than 10% of total daily dose every 1–2 weeks
Adjust rate according to patient’s pain and withdrawal symptoms
Taper even more slowly when 1/3 of total dose is reached
Dispensing interval
If patient runs out early, increase frequency (weekly, alternate days, or daily)
Endpoint
Dose well below 90 mg MEQ
Controls pain with minimal side effects
Similar or improved mood and function
Visit frequency
See patient prior to each dose decrease
Approach at each visit
Ask about withdrawal symptoms, mood, energy, alertness, pain
If pain persists, consider referral to pain clinic (if available)

34. Problematic Opioid use

35. Limiting diversion
Tell patients to store their medication in a locked box or other secure location
Tell patients not to share their medication with anyone
Avoid using fentanyl patches in elderly patients with younger adults at home (patches can be easily lifted off a sleeping patient)

36. Monitoring for problematic use
Any patient with an ongoing prescription of 40 mg MEQ or more should be monitored for signs of problematic use
At each visit, ask the patient about:
Changes in mood, relationships, functioning
Concerns expressed by family/friends
Unauthorized changes to dose, schedule (i.e., binge use), or route of delivery (e.g., biting oral tablets)
Euphoric effects immediately after taking a dose
Withdrawal symptoms
Drug-seeking behaviours: running out of medication early, frequent requests for dose increases, etc.
These features may indicate that the patient is at risk for an opioid use disorder

37. Wrap-up: Key Messages

38. Our responsibility
Prescribing opioids safely for patients suffering from chronic non-cancer pain is our responsibility as health care providers
Addiction can occur as a complication of opioid therapy
As prescribers, we need to be able to recognize the signs of addiction and know how to intervene
Effective addiction treatments are available
Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

39. Resources META:PHI website: www.metaphi.ca
META:PHI mailing list for clinical questions and discussion ( to join)
META:PHI contacts: Medical lead: Dr. Meldon Kahan Manager: Kate Hardy Knowledge broker: Sarah Clarke