Disclaimer: The information provided on this website is intended as an educational resource for health care providers only. It is not intended as a substitute for a provider’s professional medical judgement or advice.
What are the guidelines for managing patients with pain?
- Acute Pain Guidelines:
- Chronic Pain Guidelines:
- ADHS Chronic Pain Guidelines (2018) (Full Document, 198 pages, PDF).
- Veterans Affairs (VA) Guidelines (2017) (PDF).
- Summary of Guideline Recommendations (PDF).
- Decision Making Algorithms:
- DSM-5 Diagnostic Criteria for Opioid Use Disorder (PDF).
- Methadone Dosing Guidance (PDF).
- Opioid Drug Information Tables:
- Centers for Disease Control (CDC) Guidelines (2016) – CDC Mobile App.
- Pregnant and Breastfeeding Women.
How should I taper my patient off of opioids?
- There are many different factors that should go into the decision on how to execute an opioid taper, if appropriate.
- While the Arizona Department of Health Services' (ADHS) chronic pain guidelines recommend slower tapers, such as reducing morphine equivalent doses (MEDs) by 5-20 percent every four weeks with pauses in taper as needed and appropriate follow-up, there are slower and faster taper strategies that could be beneficial.
- Considerations for tapering along with example tapers, follow-up schedules, and adjunct medication for withdrawal symptoms can be found in the exit strategy section of the ADHS chronic pain guidelines (PDF).
- The VA guidelines also have a flow sheet algorithm for tapering opioids (PDF).
My patient and I have agreed to taper the opioid use. How should I go about this?
- See the ADHS guidelines section addressing exit strategies (PDF).
- Note: Tapering treatment is not the only option and may not be appropriate for every patient.
Where can I refer my patients who want to get treatment for their opioid addiction?
- Medication-assisted treatment is offered in various settings in the community that are commonly described as Opioid Treatment Programs or Office Based Opioid Treatment Programs.
- The Governor's Office of Youth, Faith and Family has a database of Prevention, Treatment and Recovery programs based on zip codes. This database also provides information on program type, services offered and payment types/insurances accepted (if given).
Do I have to register and check the CSPMP for controlled substances?
- Yes. A.R.S. § 36-2606 requires each medical practitioner who is licensed under Title 32 and who possesses a DEA license to register with the CSPMP. Each DEA license should have an associated registration. There is no fee to the practitioner for this registration. This registration includes: MD, DO, DDS, DMD, DPM, HMD, PA, NP, ND and OD. CSPMP Website (login required)
I am a resident and I use my hospital’s DEA. How do I register for a CSPMP account?
- Residents may register using the hospital DEA number and appropriate suffix.
Does the CSPMP show all controlled substances that have been dispensed to a patient?
- Yes, though it will not include methadone administered through a treatment program. Methadone treatment programs are exempt from reporting to the AZ CSPMP, so these patient profiles may not be complete.
Where can I find the standing order to dispense naloxone?
- Standing Order (PDF).
Where can I find instructions on how to administer naloxone?
- Naloxone Brochure (PDF).
Is there any naloxone training for pharmacists and pharmacy technicians?
- The Arizona Pharmacy Association has a CE training program designed for pharmacists and pharmacy technicians.
The Narcotics Anonymous (NA) program is a great peer-to-peer support group.
- Mission: "Narcotics Anonymous is a nonprofit fellowship or society of men and women for whom drugs had become a major problem. We are recovering addicts who meet regularly to help each other stay clean. This is a program of complete abstinence from all drugs."
Continuing Medical Education (CME) credits for opioid prescribing:
- Safe Opioid Prescribing for Acute Dental Pain.
- CDC Opioid Prescribing CME Courses.
- SAMHSA Opioid Prescribing CME Courses.
- Safe and Effective Opioid Prescribing CME Courses.
Is there any naloxone training for pharmacists and pharmacy technicians?
Are there exceptions when buprenorphine may be administered (not prescribed) by a practitioner without the DATA 2000 waiver?
- Yes. Exceptions when buprenorphine may be administered by a practitioner without the DATA 2000 waiver.
What are the qualifications to become a buprenorphine prescribing physician?
I have read through the qualifications. How do I apply for a physician waiver?
I am a Nurse Practitioner (NP) or a Physician Assistant (PA). How can I become a buprenorphine prescriber?
I have read through the qualifications. How do I apply for a NP or PA waiver?
I am currently able to prescribe buprenorphine, but I want to increase my patient limit.
As a pharmacist, is there any way I can verify if a practitioner is able to prescribe buprenorphine?
Are there any guidelines for managing an inherited pain patient?
Screening tools for patients at risk of opioid misuse/abuse:
- The Opioid Use Disorder Diagnostic Criteria (PDF) stratifies patients into mild, moderate or severe risk of opioid use disorder.
- The Opioid Risk Tool (PDF) is a validated, self-report screening tool to assess risk for opioid abuse among individuals prescribed opioids for treatment of chronic pain.
- The Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R) is a validated tool for clinicians to help determine how much monitoring a patient on long-term opioid therapy might require.
How do I assess my patient for opioid withdrawal?
- There are a variety of withdrawal scales online such as the Clinical Opiate Withdrawal Scale (PDF) but none should replace the clinical judgment of the provider.
Are there any sample forms or policies available to help guide management of these types of patients?
- Sample forms:
- Patient Agreement Forms (ADHS) (PDF).
- Informed Consent Form (ADHS) (PDF).
- Checklist for prescribing opioids for chronic pain (CDC) (PDF).
- Clinical Policy (University of Michigan) (PDF).
How do I evaluate a patient for Opioid Use Disorder (OUD)?
- Refer to the How to Evaluate Patients for an Opioid Use Disorder section from the ADHS Guidelines (PDF).
How do I safely and effectively taper a patient off of opioids?
- See information on Tapering.
Are there any potential pitfalls concerning the urine drug screen for opiates and opioids?
- Yes. Understanding threshold values, false positive and false negative results are crucial. VA Opioid Toolkit has a section on interpreting urine drug screens (PDF).
What about surgical, pediatric, elderly or other types of special population patients? Should I approach them all in the same way?
- No. These types of patients are addressed in the ADHS guidelines' Special Population section (PDF).
I want to switch my patient from one opioid to another. How can I figure out the right dose?
- Use tools such as the Global RPH Converter (Calculator) to help calculate conversion doses.
- Use the CDC MME Conversion Chart (PDF) to help decide a conversion dose.
- NOTE: Do not forget about cross-tolerance reduction. When switching from one opioid to another, equianalgesic dosing may prove to be too high of a dose due to incomplete cross-tolerance.
- Source: Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-30. PMID 19187889.
- The American College of Obstetricians and Gynecologists (ACOG) Guidelines for dealing with opioid use disorder in the pregnant/breastfeeding population highlights:
- Screening for substance abuse should be a part of comprehensive obstetric care and should be done with validated screening tools such as:
- For pregnant women with an opioid use disorder, opioid agonist therapy is the recommended therapy and is preferable to medically supervised withdrawal. Withdrawal is associated with high relapse rates, which can lead to worse outcomes.
- Breastfeeding should be encouraged in women who are stable on their opioid agonists, who are not using illicit drugs, and who have no other contraindications, such as human immunodeficiency virus (HIV) infection. Women should be counseled about the need to suspend breastfeeding in the event of a relapse.
- Access to adequate postpartum psychosocial support services, including substance use disorder treatment and relapse prevention programs, should be made available.
- Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants (2MB, 165 pages, PDF).
- For consultations about these special populations, please consider referring to the MotherToBaby.org specialists at (888) 285-3410.
What opioid agonist medications can be used in the pregnant/breastfeeding population?
View full ACOG guidelines for an in-depth explanation of recommendations.
What’s the law on giving methadone or other narcotics for acute opioid withdrawal to my patient in the hospital?
Who should I report pain management clinics that I have reason to believe are operating as pill mills?
- All complaints should go to the Arizona Department of Health Services: Public Health Licensing for pain management clinics:
Who should I report to if I believe another prescriber is inappropriately managing a patient?
- You should report the prescriber to his or her appropriate state board.
- The OAR Line is not a reporting agency and does not report to the state boards on behalf of others. The contact information for the various Arizona state boards are below:
- Arizona Medical Board: 480-551-2700.
- Arizona Regulatory Board of Physician Assistants: 480-551-2700.
- Arizona Board of Osteopathic Examiners in Medicine and Surgery: 480-657-7703.
- Arizona State Board of Dental Examiners: 602-242-1492.
- Arizona State Board of Nursing: 602-771-7800.
- Arizona State Board of Pharmacy: 602-771-2727.