Resource for patients seeking continued opioid or benzodiazepine therapy

To:

From:

All healthcare providers

Sarah Rudman, MD, MPH
Deputy Public Health Officer

The County of Santa Clara Public Health Department recently learned of a large number of patients prescribed long-term opioid or benzodiazepine therapy who have lost access to their usual prescriber or are likely to lose access in the near future. 

When a patient treated with opioids or benzodiazepines suddenly loses access to prescribed medication, they are at risk of severe withdrawal and may seek illicit sources of controlled substances to avoid withdrawal. These unregulated sources may contain variable doses and/or adulterants, such as fentanyl, dramatically increasing risk of overdose.

We are alerting hospitals, emergency departments, and clinics that you may encounter an influx of such patients, and we are here to assist you with resources to serve them. 

The Public Health Department is dedicated to supporting health care providers in serving patients impacted by controlled substances and addiction. Additional information and resources for these recommendations are provided below. Please contact the Harm Reduction Program at (408) 792-5529 for additional provider support. 

1. Continue opioid therapy for patients transitioning to a new provider.
   Abruptly stopping opioid or benzodiazepine therapy has been shown to increase illicit drug use, mental health crises, and death from overdose and suicide. Evidence-based practice guidelines recommend considering continued therapy until the patient can be linked to ongoing care. When possible, discuss the patient’s history with their former provider, complete baseline assessments of pain, and review expectations for opioid prescribing.

2. Assess the patient for opioid use disorder and discuss treatment options.
   This checklist based on the DSM-5 criteria for opioid use disorder (OUD) can be used to assess patients. Medications for opioid use disorder (MOUD) should be discussed with patients with patients identified to have OUD. 

   Any licensed prescriber may prescribe buprenorphine for MOUD, as there is no longer a federal requirement for an X-waiver. Additional 24/7 provider support for rapid buprenorphine starts is available through the California Substance Use Hotline (844) 326-2626.

   Additional options for linkage to MOUD include:

   1. County Narcotic Treatment Centers: (800) 704-0900
   2. Public Health Harm Reduction Program, which offers linkage to low-barrier MOUD services: [email protected] or (408) 792-5529. 

3. Develop a patient-centered, individualized care plan. If tapering opioids, use slow tapers, and document all patient care decisions. 
   Develop an individualized plan in collaboration with the patient. More information on designing a care plan is available through this guide for primary care providers. Note that safe tapers may take months to years to accomplish and a decrease in dosage of 10% per month is usually a reasonable starting point. More information on opioid tapers can be found here: Pocket Guide: Tapering Opioids for Chronic Pain (cdc.gov). Include discussions around social support, mental health services, alternative pain management strategies, and overdose risk. 

   Lastly, document in the medical record the rationale for continuing or modifying a patient’s opioid therapy. Include descriptions of pain, functional and social assessment, previous and current therapy, assessment of risk and evidence for OUD, and opioid stewardship measures. Comprehensive documentation benefits both the patient and provider. 

4. Ensure patients have access to naloxone.
   Naloxone can save a life by reversing an opioid overdose. Ensure that patients have access to naloxone and know how to use it. Naloxone is available at pharmacies. Patients can also obtain free naloxone by visiting one of the Harm Reduction Program sites or at additional venues supplied through the Santa Clara County Opioid Overdose Prevention Project.
   
   Additional resources:
   1. CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022
   2. CA Bridge Clinical Resources: Tools - Bridge to Treatment
   3.  Opioids and Chronic Pain: A Guide for Primary Care Providers. Center for Innovation in Academic Detailing on Opioids. 2023
   4. Inherited Patients on Opioids for Chronic Pain – Considerations for Primary Care. NEJM. 2022