Patients on long-term opioid therapy: Five key considerations

In brief:

• When managing patients on long-term opioid therapy, it’s important to take a holistic approach, and to be familiar with relevant resources and College policies.
• If you feel unclear on your duty to report regarding opioid abuse, contact the CMPA.

Patients with chronic, non-cancer pain might be on high-dose or long-term opioid therapy. Here are key considerations regarding your medico-legal risk when treating these patients.

1. With new patients, manage expectations

Your medical regulatory authority (College) might have policies stating that physicians cannot decline new patients solely due to opioid use. When meeting with prospective patients who are already using long-term opioid therapy, you should discuss current chronic pain management guidelines and describe your own approach to chronic pain treatment.

2. Review relevant policies and guidelines

Some Colleges and medical associations or federations have policies about prescribing opioids safely, or guidance on discontinuing long-term use if applicable. Clinical practice guidelines such as the Guideline for opioid therapy and chronic non-cancer pain support appropriate prescribing to reduce associated harms. The Opioid Manager from McMaster University may also be useful as a point of care tool. Physicians should familiarize themselves with available tools and resources.

3. Be aware of tapering strategies

If you are uncomfortable with a patient’s current prescriptions, you should assess the patient’s pain, function, and risk for opioid misuse, and revisit the goals of their care. If you are thinking about tapering strategies, consider collaborating with pharmacists or addiction specialists, who can provide support in the form of additional resources, counselling, and follow-up.

4. Consider opioid contracts

Opioid contracts that feature clear descriptions of medication use and misuse, as well as consequences for contract violation, can be a helpful measure at the beginning of a patient’s opioid treatment. You can also communicate with patients who are already using opioids about potentially introducing these contracts.

5. Understand your duty to report

If you suspect a patient of opioid abuse, you might be contemplating reporting to motor vehicle licensing authorities, child protective services, or professional regulatory authorities. In other instances, you may suspect a patient of diversion or prescription fraud. Familiarize yourself with College policies and guidelines on reporting, as well as relevant provincial or territorial legislation, and contact the CMPA if you are uncertain about your duty to report.

Additional reading

• Preventing the misuse of opioids

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.