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.

Tapering

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?

Referrals to Medication Assisted Treatment

Where can I refer my patients who want to get treatment for their opioid addiction?

  • Patients living in Kingman, Mesa, Phoenix, Prescott Valley or Tucson:
    • Locate an Opioid Treatment Center for Excellence (PDF) (open 24 hours a day, seven days a week) providing immediate access to opioid treatment and connection to ongoing services.
    • 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).
Controlled Substances Prescription Monitoring Program (CSPMP)

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.
Naloxone

Where can I find the standing order to dispense naloxone?

Where can I find instructions on how to administer naloxone?

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.
Self-Management Strategies - Chronic Pain

Are there non-pharmacological strategies for patients dealing with chronic pain?

  • The ADHS website contains information on what is chronic pain, self-management tips and info, and resources to other organizations with helpful information.
  • Another recommendation is the Healthy Living with Chronic Pain workshops that are offered by the Arizona Living Well Institute.
    • Workshops offered for 2 ½ hours, once a week, for six consecutive weeks. Throughout the workshop, participants have the opportunity to learn and practice many self-management skills. Healthy Living with Chronic Pain specifically addresses addiction, proper use of pain medication and use of opioids. Workshops are reimbursable by AHCCCS through the Regional Behavioral Health Authorities.
Self-Management Strategies - Peer Support

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."

 

Buprenorphine Prescribing

Are there exceptions when buprenorphine may be administered (not prescribed) 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?

Patient Management

Are there any guidelines for managing an inherited pain patient?

Screening tools for patients at risk of opioid misuse/abuse:

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?

How do I evaluate a patient for Opioid Use Disorder (OUD)?

How do I safely and effectively taper a patient off of opioids?

Are there any potential pitfalls concerning the urine drug screen for opiates and opioids?

What about surgical, pediatric, elderly or other types of special population patients? Should I approach them all in the same way?

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.
Pregnant and Breastfeeding Women
  • 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.

Treating Opioid Withdrawal in the Hospital

What’s the law on giving methadone or other narcotics for acute opioid withdrawal to my patient in the hospital?

Complaints

Who should I report pain management clinics that I have reason to believe are operating as pill mills?

  • All complaints should go to the licensing unit for pain management clinics:
    602-364-3030.

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:
    • Medical Board: 480-551-2700.
    • Physician Assistant Board: 480-551-2700.
    • Osteopathic Board: 480-657-7703.
    • Dental Board: 602-542-1025.
    • Nursing Board: 602-771-7800.
    • Pharmacy Board: 602-771-2727.