What are the key considerations for prescribing medications for opioid dependence in a primary care setting?

For prescribing medications for opioid dependence management in a primary care setting, several key considerations are essential to ensure safe and effective care ¹,².

• Patient Involvement and Informed Consent: Detoxification should be a readily available option for individuals who are opioid dependent and have made an informed choice to become abstinent ¹. Staff must provide detailed information to service users to obtain informed consent, covering the physical and psychological aspects of opioid withdrawal, non-pharmacological approaches, the loss of opioid tolerance and increased risk of overdose, and the importance of continued support ¹. Service users should also receive advice on lifestyle aspects such as a balanced diet, adequate hydration, sleep hygiene, and regular physical exercise during detoxification ¹.
• Medication Choice: Methadone or buprenorphine should be offered as the first-line treatment for opioid detoxification ¹. When deciding between these, healthcare professionals should consider the Department of Health and Social Care (DHSC) guidance on buprenorphine over methadone and the service user's preference ¹. If the service user is already receiving maintenance treatment, detoxification should normally start with the same medication ¹. Lofexidine may be considered for individuals who have made an informed decision not to use methadone or buprenorphine, wish to detoxify quickly, or have mild or uncertain dependence ¹. Clonidine and dihydrocodeine should not be used routinely for opioid detoxification ¹.
• Managing Co-occurring Conditions: If a person is alcohol dependent, alcohol detoxification should be offered, ideally before opioid detoxification in a community setting, or concurrently in an inpatient setting ¹. For benzodiazepine dependence, healthcare professionals should consider benzodiazepine detoxification, taking into account the person's preference and the severity of dependence for both substances when deciding on concurrent or separate treatment ¹.
• Safe Prescribing Practices and Monitoring: When initiating treatment, start with a low dose and agree frequent, regular reviews to ensure timely adjustments for effectiveness, safety, and acceptability, aiming for the lowest effective dose ². Avoid automatically increasing the dose if the response is not sustained once an effective dose has been established ². Steps should be taken to reduce the risk of developing problems associated with dependence, such as starting at a low dose and considering avoiding modified-release opioids ². Provide comprehensive information to the person about the medicine, including its purpose, intended outcomes, starting dose, dose adjustments, who to contact for problems, duration of treatment, risks of taking more than the prescribed dose, overdose symptoms, and plans for regular reviews ². The duration of each prescription must reflect the management plan and comply with best practice in controlled drugs prescribing and relevant legislation ². Regular reviews are crucial to ensure that the benefits of the medicine continue to outweigh potential harms and to check if dose adjustments are needed ². When taking over a person's care or continuing a prescription from another healthcare professional, exercise the same level of care as if starting the prescription, ensuring sufficient knowledge of the person's health and preferences ².
• Risk Awareness: It is critical to inform service users about the loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose and death from illicit drug use, which can be potentiated by alcohol or benzodiazepines ¹.