Knowledge guides

LG 16: Prescribing for opioid dependence

Clinical sciences

Advanced Trainees will describe the principles of the foundational sciences.

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Eligibility considerations

Advanced Trainees will assess the patient’s current condition and plan the next steps.

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Less common or more complex patient considerations

Advanced Trainees will understand the resources that should be used to help manage patients.

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Undertaking therapy

Advanced Trainees will monitor the progress of patients during the therapy.

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Post therapy

Advanced Trainees will know how to monitor and manage patients post-therapy.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management, and integrate these into care.

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  • Evidence supporting opioid agonist treatment (OAT) as a harm reduction measure
  • Key quality use of medicines (QUM) principles:
    • prescribing for patients at higher risk for adverse drug events
    • safety and continuity of care in transfer of prescribing
  • Low threshold, low treatment engagement versus high threshold, high treatment engagement – tailoring for the patient
  • Overview toxicology and approaches to:
    • a poisoned patient
    • liaison with emergency department (ED) and psychiatry in overdose (OD) cases
    • management of common toxidromes (intoxication)
    • OD of substances commonly used
  • Pharmacology and toxicology of opioids commonly consumed in Australia and Aotearoa New Zealand
  • Pharmacology of medications used in OAT
  • Underlying harm-reduction role of OAT
  • Rapid induction onto buprenorphine (sublingual) and induction onto long-acting depot buprenorphine
  • Determination of risks associated with opioid use in each individual patient
  • Diagnosis of opioid dependence
  • Polydrug use and associate risks, particularly alcohol and sedatives
  • Buprenorphine (BUP) to methadone
  • Chronic pain and opioid use disorder
  • Complex presentations, such as mixed intoxications and withdrawals
  • High dose treatment considerations, and approach to suspected enhanced metaboliser problem
  • Management of OAT during acute hospital admissions
  • Medication interactions with methadone
  • Methadone to BUP transfers
  • OAT in patients with severe cardiac, hepatic, and kidney disease
  • Patients who insist on methadone only, despite history of problems with methadone treatment
  • Polydrug use and risks this may present for OAT
  • Post OD in ED, and Medication Assisted Treatment for Opioid Dependence (MATOD) induction
  • Pregnancy and OAT
  • Prescribed sedatives, such as:
    • benzodiazepines
    • gabapentinoids
    • z-drugs
  • QT prolongation with methadone
  • Role of opioid antagonists
  • Specific risk considerations, including:
    • adolescents
    • occupational risks, such as pilot, bus driver, or surgeon
    • parenting and child safety
    • people with disability
  • Treatment in people with impaired capacity / cognitive impairment
  • Treatment in young adults and older people
  • Treatment provision for remote patients
  • Cautious induction with methadone
  • Culturally safe treatment services for Aboriginal and Torres Strait Islander people and Māori
  • Microinductions from full opioid agonists onto BUP
  • Monitoring treatment, including:
    • hospital presentations
    • liaison with pharmacy
    • treatment outcome measures
    • urine toxicology
  • Other approaches with BUP; rapid induction while avoiding precipitated withdrawal
  • Take home naloxone discussion
  • Therapeutic implications for other special populations, such as:
    • adolescents
    • LGBTQIA+ peoples
    • pregnant people
    • prisoners
    • rural and remote
  • Treatment with long-acting BUP injection
  • Long-term trajectories of patients who have engaged in OAT, and relapse risk
  • Optimising transitions between specialist services and primary care or custodial services
  • Planned cessation of OAT
  • Unplanned cessation of treatment
  • Designing and operating services and service systems to meet the needs of Aboriginal and Torres Strait Islander people and Māori
  • Differentiating between physiological opioid and sedative / hypnotic dependence and opioid use disorder and sedative / hypnotic use disorder
  • Ensuring hospitals have guidelines for ongoing management of OAT for admitted patients
  • Ensuring transitions are as smooth as possible between services, including specialist services, primary care, and custodial services
  • High-priority patients for OAT
  • Legal aspects of opioid prescribing in relevant jurisdictions and administrative requirements
  • Management of benzodiazepine withdrawal
  • Managing patients with chronic pain and opioid dependence, and advising other prescribers regarding de-prescribing, formal OAT, and the various risks
  • Medications in stimulant use disorder
  • Naltrexone, disulfiram, and acamprosate (Australia only) for alcohol relapsed prevention
  • Newer medications in addiction medicine, such as baclofen, gabapentin, and topiramate
  • Ongoing advocacy and actual supporting structures for OAT in primary care