McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Cluster 5: Managing Opioid Misuse and Addiction in CNCP Patients

R24. Recommendation Statement

No. Recommendation Keyword
R24 Acute or urgent health care facilities should develop policies to provide guidance on prescribing opioids for chronic pain to avoid contributing to opioid misuse or diversion (Grade C). Acute care opioid prescribing policy
  • R24. Discussion

R24. Discussion

Physicians providing care in acute/urgent healthcare facilities need to respond appropriately to patients with pain and to those who are seeking drugs for misuse or diversion. An opioid-prescribing policy, which takes the local community needs into account, could serve to:

1. Provide a framework to facilitate a consistent response from all physicians. (Note: inconsistent policy application can encourage drug seekers "targeting" liberal prescribers.)

2. Act as a deterrent for individuals attempting to obtain opioids for diversion or misuse.

Patients with pain are routinely seen in acute/urgent healthcare facilities (e.g., emergency departments and walk-in clinics). Physicians assessing and treating these patients need to distinguish between pain that is acute, originating from an injury or other mechanism, or chronic. This is complicated by various scenarios:

  • Some patients have chronic recurrent pain and may present in an "acute" episode of a chronic pain condition.
  • Patients who are abusing or addicted to opioids or who are drug diverters may visit these settings specifically in an attempt to obtain opioids.
  • Patients report they are on LTOT, have run out of their medication, are unable to access their usual care provider, and ask for a temporary prescription: they could be from another area, province, or country.

The following topics are suggested to assist physicians in creating an opioid-prescribing policy:

1. Development: Participation by all physicians providing care in the acute/urgent healthcare setting can be useful in addressing the issues and promoting adherence.

2. Policy Availability: The policy could be posted in the waiting area of the facility, and/or available as a handout, to provide patients with information in advance of seeing the physician.

3. Legislation: The policy should comply with provincial legislation about opioid prescribing, and accessing and sharing patient information.

4. Opioid Prescribing: The policy should outline circumstances for prescribing and not prescribing. For example, for patients who report they are established on opioids with another prescriber, but have run out, a policy could include requirements and limits of issuing a prescription, such as:

  • Contact must be made with the prescribing physician or dispensing pharmacist.
  • Number of doses prescribed is limited to last until the next business day.
  • Dose is amount that the physician feels is appropriate, given the patient’s underlying pain condition, even if that dose is considerably less than what the patient reports receiving.
  • The facility prescribes once only for patients who have run out.
  • A record of the visit is sent to the primary-care physician.

5. Suspected Opioid Addiction: The policy could indicate a response to patients who appear addicted to opioids, e.g., provide information about addiction resources for treatment.