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Opioid therapy is not right for every patient, however, for some, this may be a reasonable option. You should always try non-opioid therapies before considering opioid therapy and understand the benefits, risks, and alternative options before starting opioid therapy. Often our treatment plan will be combined with non-opioid therapies. It is important that you establish treatment goals to improve pain and function. Patients undergoing opioid therapy are usually required to sign a treatment agreement with our provider. It is your responsibility to read your treatment agreement and informed consent before starting opioid therapy. This agreement usually stipulates that you will only receive opioids or other controlled medications from one provider/clinic. Often these will usually be in association with a monthly office visit for therapeutic drug monitor and appropriate medical supervision. You should always follow all office policies in your treatment agreement. Safety monitoring will usually include but is not limited to routine urine drug screening and CURES monitoring. Only use medications as prescribed. You should NEVER take more than prescribed and taking more medications than prescribed increases the risk of significant adverse events such as death. You must lock up all your opioid medications in a safe. “In 2008, nearly 36,500 Americans died from drug poisonings, and of these, nearly 14,800 deaths involved opioid analgesics.” --FDA “Almost 16,000 Americans died of overdose involving opioids in 2009.” -- FDA “In 2009, there were nearly 343,000 emergency department visits involving nonmedical use of opioid analgesics.” --FDA “Based on the 2010 National Survey on Drug Use and Health, public health experts estimate more than 35 million Americans age 12 and older used an opioid analgesic for non-medical use some time in their life—an increase from about 30 million in 2002.” --FDA “In 2011, an estimated 22.9 million prescriptions for extended-release and long-acting opioids were dispensed in the U.S.” -- FDA “80% of the world's pain pills are consumed in the United States.” -- American Society of Interventional Pain Physicians. “The total annual incremental cost of health care due to pain ranges from $560 billion to $635 billion (in 2010 dollars) in the United States, which combines the medical costs of pain care and the economic costs related to disability days and lost wages and productivity. In 2010 there were an estimated 100 million Americans dealing with chronic pain.” – AAPM “Accidental overdoses from prescription drugs now exceed the combined total of deaths from heroin, crack, and methamphetamines. Accidental deaths from overdoses resulting from legal prescription drugs now exceed deaths by car accidents.” – CNN “Every 19 minutes someone dies from a drug overdose in the United States. This number includes those dying from both legal and illegal drugs; however, most are due to legal prescription drugs. ” – Dr. Sanjay Gupta “I just want people to remember: opioid addiction is a deadly disease, it kills people all the time, we are dealing with a fatal illness more likely to kill you than the vast, vast, vast majority of cancers—that’s a fact” – Dr. Drew Pinsky “The medications don’t pull the trigger, but the failure to educate ourselves and our patients about the safe use of these medications is deadly.” – Dr. Yogi

Opioids can be a life changing medication for many patients with chronic pain, if used responsibly. Opioids have great potential to ease pain; however they have equal potential for deadly side effects and misuse as stated before. Opioids mimic the actions of endogenous opioid peptides by interacting with mu, delta or kappa opioid receptors. Opioids work by binding to opioid receptors in the central and peripheral nervous system were they produce analgesic effects by decreasing the perception of pain, decreasing your reaction to pain, and increasing pain tolerance. They do not have an effect on the source of the pain, such as anti-inflammatory medications by reducing inflammation. There are many types of nerve fibers in our body. The two main nerve fibers types that are involved in the perception of pain are known as C-fibers and A-delta fibers. When opioids bind opioid receptors located on these nerve fibers they block the release of pain neurotransmitters (through a complicated process which we do not need to discuss here otherwise you would fall asleep reading it). The blocking of these neurotransmitters, such as glutamate, substance P, and calcitonin gene-related peptide from the nociceptive fibers, results in analgesia (i.e. pain relief). Opioids also bind to other opioid receptors throughout the body, such as gastrointestinal tract, producing unwanted side effects such as constipation, respiratory depression, and sedation. They also often produce euphoria, which is one of the reasons their use can lead to abuse, misuse and addiction

Opioid therapy is not right for everyone. Your doctor will determine after taking a through physical and medical history if the use of opioid therapy is an appropriate option to add to your treatment plan. Opioid therapy should never be the only treatment option used to treat your pain. The use of adjuvant therapies and non-drug therapies are important parts of a successful treatment plan. When it comes to opioid therapy, proper patient selection is critical. Your doctor will consider a trial of chronic opioid therapy only when potential benefits are likely to outweigh risks. Before the trial you may be asked to sign a treatment agreement with your physician that will outline the expectations, safe use and office policies with regards to your treatment plan with or without opioid therapy. It is important that you read and understand these contracts fully. In patients who experience mild or moderate opioid-related adverse effects, a longer trial may be indicated, because some adverse effects diminish with longer exposure. Some adverse effects can be managed with additional therapies (e.g., a bowel regimen for prevention or treatment of constipation). Your physician will also ask you a multiple of questions to help determine the benefits and risks of opioids in your treatment plan. Studies have shown that the list of risk factors below are associated with a higher risk of opioid addiction and misuse. FACTORS ASSOCIATED WITH HIGHER RISK OF OPIOID MISUSE History of Substance Abuse History of Alcohol Abuse Family History of Substance Abuse History of DUIs History of Lost or Stolen Prescriptions Use of Supplemental Sources to Obtain Opioids History of Psychiatric or Psychological Disorders History of Sexual Abuse During Childhood Male Sex Younger Age It is important for you to provide your physicians with an accurate history and inform them if you have any of the above risk factors, as this is necessary for the delivery of safe care. Research indicates that many forms of chronic pain can respond to chronic opioid therapy, although there is little evidence that opioids are effective when there is a strong untreated psychological component to the pain. Before starting opioid therapy your physician may send you for a consultation with a pain psychologist. Psychological assessment is important when initiating therapy. It offers one promising avenue to detecting and balancing the risks of opioid therapy. Safety is the biggest priority with the use of opioids for chronic pain management. The CDC and Medical Board of California both recommend patients with an above-average risk also consider a consult with a specialist in addiction medicine or similar specialty. It is typically performed twice a year. Factors that place patients at above-average risk include but are not limited to: higher than average doses of opioid medications, co-use with benzodiazepines or sedative medications, inconsistent CURES or UDS, Risk Evaluation (ORT) scores >3, etc. Your physician may use the aid of a screening instrument when trying to determine if opioid therapy would be appropriate. Several screening tools have been extensively validated and include: the Screener and Opioid Assessment for Patients with Pain (SOAPP) Version 1, the revised SOAPP (SOAPP-R), the Opioid Risk Tool (ORT), and the Diagnosis, Intractability, Risk, Efficacy (DIRE) instrument. It is important to be truthful during the screening process. For all patients starting on opioid therapy, the treatment plan must be individualized. Initial use of opioids should be viewed as a short-term therapeutic trial lasting several weeks to several months. The decision to continue chronic opioid therapy after this period should be based on outcomes during the trial. Your physician will evaluate you for the degree of analgesia, improvement in activities and goals, degree of adverse effects, and signs of aberrant drug-related behaviors. You should always set realistic expectations, and your physicians will work with you to develop SMART goals: Specific, Measurable, Achievable, Relevant, and Time-bound goals. For example, setting a concrete goal of being able to walk 20 minutes a day, 3 days a week by the next clinic visit is much more attainable than the goal “to feel like I did when I was 20 years old”. Your provider will be looking for 5 main criteria to determine that you are benefiting from opioid therapy. This is often referred to as the “5As Of Opioid Therapy”. The medications should provide you Analgesia (pain relief), cause minimal Adverse side effects, improve your ADL (activities of daily living) and function, evaluate that you have good Affect (mood), and make sure you are not showing any Aberrant behavior such as overuse or abuse of your medications. You should always attempt to understand your underlying diagnosis and chronic conditions. For example chronic migraine suffers should be able to explain to others what a migraine is. Knowledge is power and the more you know about your condition the better you will do. It is not uncommon for provider to give some of their patients “homework”, in the form of essay writing, when they feel it is necessary for them to obtain additional education about their underlying conditions. Two important areas to discuss with your doctor with regards to your initial assessment of opioid therapy are any sleep disturbances and/or history of anxiety and/or depression. These three comorbid disease often are very common with chronic pain. Not only can they make chronic pain worse, chronic pain can increase the risk of developing these comorbid disease and turn into a vicious cycle. Thus it is important to together develop a treatment plan that will address these issues in addition to the treatment plan created to address your pain. If you ever develop suicidal thoughts or ideas it is important to immediately notify your provider or go to the nearest hospital.

By now you have realized that this tutorial often repeats multiple times a similar point in different ways. This is not because we love to ramble on, but this is intentional as these points are the key points to this tutorial. Some research has shown that it takes multiple exposures to information before they become engraved into your brain. Some experts say it takes 16-21 times to make something a habit! Use opioid medications for acute or chronic pain only after determining that alternative therapies do not deliver adequate pain relief. The lowest effective dose of opioids should be used. When starting you on opioid therapy your physician will account for your opioid history, physical tolerance, and consideration of agents in mixed preparations, cross-tolerance, and conversion irregularities. It is always best to use caution when initiating and increasing opioid regimens. There have been many debates as to the safe range with regards to opioid therapies. When taking about opioid medications many often refer to what is known as morphine equivalent dose (MED). Maximum safe dose is patient-specific and dependent on current and previous opioid exposure, as well as on whether the patient is using such medications chronically. Your doctor will slowly titrate up your dose until adequate pain relief is seen or side effects preclude further escalation. The current guidelines do recommend consultation with a pain specialist if you are taking above a certain amount of opioid medications. If a patient’s dosage has increased over 120 mg MED per day, without substantial improvement in function and pain, they should consider seeking a consultation from a pain specialist. High dose opioid therapy has not been shown to be superior to lower dose treatment plans. Some studies have shown that risks of adverse events increase at doses at or above 120mg MED, therefore you should always try to decrease your overall dose of opioids as you medical condition improves or when possible. RECOMMENDED DOSE THRESHOLD FOR PAIN CONSULTATION OPIOID SPECIFIC PRECAUTIONS Current opioids such as methadone should only be prescribed only by a pain medicine specialist or a physician thoroughly trained on the use of methadone. Safety concerns with methadone are due to its sometimes unpredictable pharmacodynamics and pharmacokinetics. Methadone is difficult to titrate due to its half-life variability. It may take a long time to reach a stable level in the body. Methadone doses should not be increased more frequently than every 7 days. Never take more than prescribed when it comes to Methadone, as it can seriously lead to overdose and death. Inform your doctor if you have or develop COPD, CHF, sleep apnea, alcohol or substance abuse, are over 65 years of age, or have history of or develop renal or hepatic dysfunction. These conditions may potentiate opioid adverse effects and require close monitoring. Even low doses of opioids can lead to more risks than benefits in some. One of the major concerns with ongoing opioid therapy includes the risk of tolerance as explained in the terminology section. One tool your physician may use to deal with tolerance is known as opioid holiday or opioid rotation. Opioid holiday usually is initiated when you are slowly titrated off your opioid medications with the help of your physician, and then allow a certain amount of time in which you are not exposed to opioid medications. This may allow your body to “reset its opioid receptors”, thus when opioid medications are restarted they become effective at lower doses and thus reduce side effects while increasing efficacy. Opioid rotation is defined as a change in opioid drug or route of administration with the goal of improving outcomes. Switching from one opioid to another is often necessary to realize the most favorable balance of therapeutic effects and side effects in patients who require chronic opioid analgesic therapy as a component of overall pain management. Your physician will use what is known as an opioid conversion table when switching you to another pain medication. This conversion table with help your physician select a safe starting dose for the new opioid medication. It is always best to start low and error on the side of safety and slowly titrate up if needed, rather than start high and risk overdose. Due to opioid cross tolerance opioid cross-tolerance experts actually recommend that a dose reduction of up to 50% is appropriate and safe when switching from one opioid to an alternative (SUBOXONE®) It is important to discuss a medication that is often used to treat addiction in individuals who have chronic pain but also have opioid dependence or additional concerns. This medication is known as Suboxone®. Suboxone® contains a combination of buprenorphine and naloxone. This should not be confused with Subutex® which is an opioid medication that only contains buprenorphine. Buprenorphine is an opioid medication, thus Suboxone® is an opioid medication as well. It has less risk of addiction due to the addition of naloxone and the fact that buprenorphine is a part-agonist and binds strongly to the opioid receptor often blocking the effects of other opioid medications. The basic issue with analgesia in the buprenorphine-maintained patient is that while buprenorphine has analgesic properties, it is a partial agonist. This means that not only will it block the cravings associated with opioid dependence, but because of the high affinity of buprenorphine for opioid receptors it may also block the analgesic effect of OTHER opioids. However since buprenorphine itself binds strongly to the opioid receptor it provides analgesia and is often used to treat moderate to severe chronic pain. You physician may recommend you see a pain medicine specialist trained and licensed to use Suboxone® if they are concerned with you developing opioid dependency and/or opioid addiction. Suboxone’s® labeled use and indication is for opioid dependence. However since it contains buprenorphine is does provide analgesia in patients with chronic pain. Suboxone® can only be written by specially trained and licensed physicians. If you are on Suboxone® you should read fully the medication guide that you received from the pharmacy when you obtained your medication. The labeled uses of Buprenorphine include both management of moderate to severe chronic pain only in the patch form (i.e. Butrans®) and the treatment of opioid dependency, Suboxone®. Of note the Butrans® patch is a patch that contains the medications buprenorphine, however the concentration of buprenorphine in the Butrans® patch is significantly less than that in Suboxone® and Subutex®, thus the Butrans® patch is a good option for patient with moderate to severe chronic pain who need around the clock opioid medications. And due to the low concentrations of buprenorphine in the Butrans® patch, most patients can still take other breakthrough pain medications, such as Vicodin® or Percocet® while on the Butrans® patch and still obtain significant pain relief from their breakthrough medications. Methadone is another drug that has a labeled indication for both moderate to severe pain as well as for the detoxification and maintenance treatment of opioid addiction through a certified program. Buprenorphine is considered to be less addictive than methadone. Use of methadone for other purposes than the treatment of pain, such as addiction, requires special training and a special license, and usually only allowed through certified programs.

Pain treatment in the elderly is an important challenge in today’s time due to increasing numbers of senior citizens, their higher incidence of pain, and their greater susceptibility to adverse effects of pain medication in this population. Opioids as a class may be less likely to cause organ toxicity than NSAIDs (i.e. GI bleeds) in senior citizens. According to these guidelines, opioid therapy for elderly patients may be safe over the long term, but can be dangerous when starting or increasing a dose. When it comes to risks of opioid use in the elderly the primary concerns are constipation, overdose, over sedation and falls. To minimize these effects the following precautions are recommended in elderly patients: lower starting doses, slower titration, longer dosing intervals, more frequent monitoring, and discontinuing (by tapering) benzodiazepine use when possible. Practical recommendations for opioid prescription in the elderly include meticulous review of indication for opioid use, not only initially but also at regular intervals thereafter. A policy of careful titration should be followed, with conservative choice of dosage on starting. Dosing intervals may need to be lengthened subsequently. It is very important in assessing concurrent or undisclosed use of medications, such as over-the-counter NSAIDs, other opioids, and benzodiazepines or other sedatives (including alcohol), that place patients at higher risk for morbidity or mortality. Assessment of the patient’s ability to reliably self-administer should also be considered, especially if signs of cognitive impairment are apparent and he or she is still living independently. As with all patients, including senior citizens it is important that you disclose all your prescription and over-the-counter medications (including alternative medications) and any alcohol consumption to your doctor. Before prescribing an opioid, an environmental assessment for potential addiction/diversion risk should be conducted. The elderly may be a target for drug theft, etc. Proper storage and limited discussion surrounding the opioid is prudent. Of all the unwanted effects of the opioids in the elderly, the most difficult to deal with is that of constipation, and severe cases can lead to deadly bowl injury. Incorporate an appropriate bowel regimen, as this is essential in preventing constipation. Laxatives may be necessary. Polyethylene glycol and lactulose have more evidence for efficacy; however, other choices such as senna or bisacodyl might be considered on the basis of an individual patient’s symptoms, toleration, and preferences. Risk of delirium from opioids, since opioids are predominantly renally excreted, increases as creatine clearance (CrCl) worsens. This can happen with acute causes of reduced renal function (e.g., dehydration or drug interactions such as with NSAIDs and angiotensin-converting enzyme inhibitors). Other causes of delirium, such as patients taking their medications incorrectly, should also be explored. One of the reasons why elderly patients are increasingly vulnerable to adverse drug effects and interactions is due to the higher rates of polypharmacy (i.e. taking a large number of different medications) and comorbidities. Aging affects opioid pharmacokinetics via altered body composition (distribution volumes) and organ function (liver = metabolism, kidney = excretion). Pharmacodynamics is affected via impaired neurotransmitter/peptide production and changed receptor affinities/populations. The net effects of changes in opioid pharmacology with age on clinical opioid analgesia remain unclear, probably due to the significantly greater variability in body function with increasing age. Pharmacokinetic factors that put the elderly at higher risk for opioid overdose than younger patients also includes lower serum binding, lower stroke volume (which acts to slow liver metabolism), as well as a greater sensitivity to the psychoactive and respiratory effects of opioids. It is important to monitor renal and liver function in elderly patients on a routine basis. Renal or hepatic impairments can lead to toxicity as most opioids are metabolized in the liver and excreted through the renal system. Methadone, propoxyphene, and meperidine are not recommended for use in elderly people and in patients with renal disease, because of the toxicity of their metabolites. Due to the fact that tolerance to the respiratory depressant effects of opioids develops slowly elderly patients with Pneumonia, COPD and/or sleep apnea are at greater risk for respiratory depression. Inform your doctor if your develop a lung disease such as Pneumonia as you may need to consider lowering your doses until the pneumonia resolves. Opioids may be a risk factor for central sleep apnea in the elderly. Elderly patients on opioid therapy also have high sleep disorders, as this may be a reflection of the effects of pain, or the sedating effects of opioids and/or concurrent depression. Last but not least elderly patients on opioid therapy are at risk of cognitive impairment. Patients with a psychiatric diagnosis or patients who live alone on opioid therapy should arrange some type of medication supervision to improve safety. Elderly patients and their caregivers should be educated to recognize signs of overdose (i.e. slurred or drawling speech, emotional instability, mood changes, incoordination, nodding off during conversation or activity) so that the appropriate steps can be taken to minimize further harm. Some recommended guidelines for elderly patients considering opioid therapy include starting initial doses at lower then the suggested initial adult dose and lengthening the time interval between dose increases. Always use weaker opioids and the lowest dose when possible, such as codeine, tramadol, hydrocodone or the Butrans patch. Among strong opioids, oxycodone and hydromorphone may be preferred over oral morphine for the elderly if constipation and sedation are an issue. Morphine should also be used with caution in patients with decreased renal function as the M-6 glucuronide metabolite of morphine accumulates and has been associated with severe adverse effects. The combination of opioids and benzodiazepines increases the risk of sedation, overdose, falls and diminished function in all patients, especially as age advances. For elderly patients who cannot tolerate pills your doctor may consider patches or solutions. Morphine solutions are useful in some situations such as patients with swallowing problems, or patients requiring less than 5 mg morphine per tablet. The two most commonly used opioid patches currently include the fentanyl patch and the buprenorphine patch, also known as the Butrans Patch. Finally, it should be remembered that untreated pain in the elderly may have further adverse effects on the health of the patient. Persistent pain and its inadequate treatment is associated with a number of adverse outcomes in the elderly including functional impairment, falls, slow rehabilitation, muscle deconditioning, mood changes, decreased socialization, poor sleep and appetite disturbance, and greater health care use and costs.

Just as starting and maintaining opioid therapy should be done with caution and only under the supervision of a trained professional, so should the discontinuation of opioid therapy. Always consult with your doctor so together you can develop a plan to safely and effectively discontinue opioids. If at any point the risk outweigh the benefits for you to continue opioid therapy we will provide you a discontinuation plan that typically involves a slow titration off opioid therapy by approximately 10% per week. There are several reasons to discontinue chronic opioid therapy for a patient who has been receiving opioids for management of a chronic pain conditions. These include medication side effects, patients wish to discontinue opioid therapy, loss of meaningful clinical benefit from the medications, misuse or concerns regarding adherence to the treatment agreement and office policies, reduction in one’s pain no longer requiring opioid therapy, and as well as changes in one’s health resulting in opioid therapy being more harmful than beneficial. Opioid rotation is an alternative to discontinuation. Patients may be wary to try another agent or may experience intolerable adverse effects with certain chemical classes of opioids. Often, implementing an “exit” strategy will involve tapering the opioid that you are taking. Weaning from opioids can be done safely by slowly tapering the opioid dose and considering several other factors. As each individual is different your doctor will tailor a tapering plan based on your needs. An accepted rule of thumb for the safe and slow tapper of opioid therapy is reduction of your current dose by 10% each week. Keep in mind that some patients can be tapered more rapidly without problems. You should not suddenly discontinue opioid therapy due to risk of withdrawal. Opioid withdrawal syndrome may be encountered and be unpleasant, but it is typically not medically serious. Please note here that although withdrawal from opioids is not considered lethal, significant withdrawal from benzodiazepines and alcohol can be deadly. Also when deciding to discontinue Soma®, you must also titrate off slowly as significant withdrawal is possible. It is normal to have concerns about tapering off long acting opioid medications due to fear and anxiety of increased pain or development of withdrawal symptoms. Typically, the last stage of tapering is the most difficult. Usually the initial tapering is well tolerated and the most difficult period of titration is when titrating off the last 30-50mg of morphine equivalents. Opioid withdrawal is typically not dangerous, but it may cause considerable discomfort. It is important to understand and recognize the symptoms of withdrawal if you experience them and inform your doctor of these side effects. Symptoms of opioid withdrawal include but not limited to: nausea, vomiting, increased heart rate, anxiety, abdominal cramps, diaphoresis, diarrhea, dilated pupils, increased respiratory rate, runny nose, muscle spasms and twitching, muscle and body aches, goose bumps, increased blood pressure, insomnia, and/or lacrimation. Consult your physicians on treatment options if needed to address withdrawal symptoms. Symptoms such as hypertension, cramps, nausea, diarrhea, muscle pain, diaphoresis, tachycardia, and myoclonus, can be managed with alpha-2 adrenergic agents, such as Clonidine, during the taper while monitoring for hypotension and anticholinergic side effects. Clonidine is not FDAapproved for this use, although evidence supports use in this setting. Group Health recommends clonidine as the first-line agent, as it is effective in many patients. Regular monitoring of blood pressure and pulse are needed. Dosing of clonidine depends on whether patient is acutely withdrawing or gradually being tapered. These are high-risk medications for the elderly. Antihistamines or trazodone® may be used to help with insomnia and restlessness. Nonsteroidal anti-inflammatory agents may be used for muscle aches, and Imodium® for diarrhea. It is important to note that symptoms of mild opioid withdrawal may be present for up to 6 months after opioid discontinuation. Other medications used to treat subjective symptoms during acute withdrawal and/or gradual taper include Hydroxyzine 25-50 mg every 6 hours as needed for anxiety, restlessness and insomnia. Diphenhydramine 25-50 mg every 6 hours as needed for itchiness. Promethazine 25 mg every 6 hours or Metoclopramide 10 mg every 6 hours as needed for nausea. Calcium carbonate (Tums®) 500 mg 1–2 tabs every 8 hours as needed for dyspepsia. Mylanta® or Milk of Magnesia® (follow package instructions) may also be used for dyspepsia. Acetaminophen (Tylenol®) 325 mg every 4-6 hours as needed for fever (not to exceed 2-3 g/24 hours, and also note that some narcotic medications already contain acetaminophen. (Always consult your own physician before taking or starting any new medications.) Often slowing the taper rate can decrease the withdrawal symptoms. Your physician may also consider the use of benzodiazepines, such as Valium®, to help overcome withdrawal symptoms; however these medications should also be used with caution due to their inherent side effects and addiction concerns and only should be used under the supervision of a trained specialist familiar with these medications. Your physician may also seek the help of a specialist such as an addictionologist should the need arise and it will be important for you to follow these recommendations. If a monitored outpatient tapering (i.e. detoxification) program is not appropriate your doctor will refer you to an inpatient detoxification program or a more advanced outpatient detoxification program. During this time it is important to continue or add non-opioid management treatment strategies. These can include non-opioid pharmacologic therapies; invasive treatments as appropriate (e.g., epidurals, trigger point injections, spinal stimulator); rehabilitative strategies (e.g., physical therapy); cognitive behavioral approaches (e.g., biofeedback), etc. Keep in mind that discontinuing opioids is not the same as discontinuing pain management, and your physician will work with you to develop additional treatment options to better help control your pain. Patients with a long history of taking chronic opioids or any centrally acting medications such as dopamine agonists and SSRIs are more likely to experience withdrawal from a taper that is too rapid, and therefore may require a longer taper period to avoid such symptoms. Your physician may consider the use of methadone as the drug of choice for the tapering process. Methadone is less likely to produce euphoria and is inexpensive compared with the other long-acting agents. It must be made clear however that the methadone is being used to treat pain, and that the taper is being done for medical reasons, not for substance abuse rehabilitation. People taking short acting medications such as morphine, hydromorphone, or oxycodone may experience withdrawal symptoms within 6 to 12 hours of the last dose while those taking methadone or controlled-release opioids will experience symptoms typically 1 to 4 days after the last dose. Withdrawal from morphine typically lasts 5 to 10 days, while withdrawal from methadone or other long-acting opioids lasts longer. Often the first three days of withdrawal are the most intense and over time these symptoms will normally improve. It is important that during the tapering process that you never break or open the medications, or cut the patches. This can release the entire dose at once, causing overdose and possible death. Instead your doctor will recommend you take the whole tablet or capsule or use the whole patch, but take or use the medication less often to reduce the dosage. Drink a lot of fluid, try to stay calm, and keep reassuring yourself that the withdrawal reaction will pass and you will eventually feel better. One of the symptoms during opioid withdrawal is a state of sensitized pain, meaning your pain may feel more intense or severe. This also will pass with time. Remember: Always seek professional healthcare assistance as soon as you can, if possible, before running out of medication.

Benzodiazepines and opioid medications are used concomitantly in various circumstances, for example in anesthesiology, for the management of acute or chronic pain and for substitution therapy. Please note here that many of the same learning points and concerns in this tutorial with regards to opioid therapy also apply to the use of benzodiazepines. Please note we do not recommend you consume alcohol while on opioid therapy. We also strongly recommend you do not start benzodiazepines. Also consider talking to your PCP about discontinuing any benzodiazepine therapy if possible. Alcohol, benzodiazepines as well as sleep medications such as Ambien when combined with opioid therapy increase your risk of respiratory depression and death. The FDA has release a black box warning with regards to the co-use of opioids and benzodiazepines (such as valium, Xanax, Clonazepam) which can lead to accidental overdose and death. It is important to try to find alternative options in place of benzodiazepines when also under opioid therapy. You should also consider a consultation with a psychiatrist or sleep specialist if needed to determine if there are more effective and safer options to address issues with anxiety and insomnia. Just as with any medications the lowest doses needed should be used and side effects should always be reported to your physician. As with co-use of benzodiazepine with opioid therapy the use of alcohol while undergoing opioid therapy also increases the risk of side effects and increases your risk of over dose and death. The combination of alcohol and opioids can be deadly, and leads to hundreds of accidental overdoses each year. Mixing alcohol with opioids causes severe respiratory problems and cardiac arrest among other numerous health concerns. If you take opioid medications regularly, you are at risk for dangerous drug interactions every time you take a drink. We strongly recommend patients do not combine alcohol use while on opioid therapy. The excessive use of alcohol is an absolute contraindication to the use of opioid therapy. If you are consuming alcohol or feel you have a drinking problem please inform your physician immediately. Patients often wonder if a small consumption of alcohol while on pain medications, such as a glass of wine with dinner is safe? This is a difficult question to answer due to individual differences between patients, and it is impossible to know in advance how much is “too much” alcohol. Concerning symptoms that you should watch out for include drowsiness, confusion, or dizziness. If you experience these side effects seek medical care immediately. Again we strongly recommend you do not consume any form or any amount alcohol while taking opioid medications as well as if you are taking benzodiazepines. Benzodiazepines combined with alcohol with or without opioid medications have similar serious concerns for overdose and death and should be avoided.

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