Primary prevention
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
GeneesmiddelenverslavingPublished by: Domus Medica | SSMGLast published: 2011Assuétude aux médicamentsPublished by: Domus Medica | SSMGLast published: 2011The National Institute for Health and Care Excellence recommends that healthcare professionals identify individuals vulnerable to drug misuse during routine contacts (such as health assessments for looked-after children or care leavers, general practitioner or nurse appointments, or accident and emergency department visits related to alcohol or drug use) using a standardised approach, assess risk factors, and make appropriate referrals. They recommend offering or referring for tailored skills training and non-judgemental advice, with follow-up and signposting to support services.[52]
The US Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing for pain are summarised here; a stated aim of the guidelines is to provide safe and effective pain treatment while reducing risks associated with opioids including opioid use disorder, overdose, and death.[53]
Prioritise non-opioid pharmacotherapy and behavioural interventions first
Set and track functional and pain goals before starting opioids; discontinue if risks outweigh benefits
Educate patients on risks, benefits, and responsibilities of opioid use
Use immediate-release opioids while starting treatment
For opioid-naive patients, prescribe the lowest effective dosage, and only increase the dosage (if required) with caution
Reassess ongoing opioid therapy regularly; consider tapering or discontinuing if appropriate
Avoid abrupt discontinuation unless there is a life-threatening concern (e.g., impending overdose)
Limit acute pain prescriptions to the anticipated minimal duration needed
Re-evaluate within 1-4 weeks of starting or escalating opioid therapy, then monitor regularly
Review the patient's history of controlled substance prescriptions before prescribing an opioid for any type of pain, and periodically during therapy for chronic pain; in the US this can be done using state prescription drug monitoring program (PDMP) data
Consider toxicology testing to assess for prescribed drugs/controlled substances before prescribing an opioid for subacute or chronic pain
Use particular caution when prescribing an opioid and benzodiazepine concurrently
Evaluate risks versus benefits when combining opioid and other central nervous system depressants (e.g., gabapentin, pregabalin, muscle relaxants, sedating hypnotics)
Other professional bodies in the US, such as the American Society of Clinical Oncology and the American Academy of Neurology, have published specialty-specific guidance for clinicians on prescribing of opioids and prevention of prescription opioid misuse.[54][55]
In 2023, the US Food and Drug Administration (FDA) updated opioid prescribing guidelines to emphasise using the lowest effective dose for the shortest duration and to highlight the risks of misuse and of unused opioids, in response to the ongoing US opioid crisis.[56] In 2025, the FDA mandated safety labelling changes to further emphasise and characterise the risks associated with long-term use of opioids, based on observational data from two studies.[57]
The American Academy of Pediatrics has published guidance on prescription of opioids for acute pain in adolescents in outpatient settings, emphasising a multimodal approach that prioritises non-opioid and non-pharmacological treatments. It offers guidance on appropriate opioid use, including avoiding codeine and tramadol in certain populations and limiting prescriptions to short-term, low-dose use when necessary.[58] In 2020, the US Preventive Services Task Force concluded that there was insufficient evidence to assess the use of primary care-based behavioural counselling interventions to prevent illicit drug use in adolescents, and young adults.[59] However, some studies show reduced substance use into adulthood among children whose parents received primary prevention interventions.[60] Examples of programmes include Guiding Good Choices (formerly known as Preparing for the Drug-Free Years), Triple P Parenting, and Familias Unidas, which have been used in the clinical setting with encouraging results.[61][62][63]
Primary prevention in adolescents may also include strategies to limit risk factors such as childhood trauma. Evidence from randomised controlled trials shows that providing guidance to low-income, first-time mothers during pregnancy and in the first 2 years of a child's life through home visitation by nurses can have a range of lasting positive impacts on the child.[64] This includes reduced abuse and neglect, as well as greater cognitive and behavioural outcomes that extend into adolescence.[64] Community programmes focusing on developmental competencies, social skills, and resilience have also been shown to reduce prescription opioid misuse in US adolescents.[64]
There is some evidence in favour of group-based interventions for reducing opioid use in people with chronic non-cancer pain.[65]
Secondary prevention
To reduce the risk of overdose-related death, all individuals treated for opioid use disorder should be routinely offered naloxone or another opioid reversal treatment.[66][69] SAMHSA: Overdose prevention and response toolkit Opens in new window For patients who continue to use illicit drugs, fentanyl and xylazine test strips are often available within treatment programmes or may be accessed by patients for personal use at home, and can help detect contaminants that increase overdose risk.[204]
Unsterile injecting practices and risky sexual behaviour among opioid users is a major contributor to the spread of HIV, hepatitis, and other infections. Counselling on safer injection practices for those who inject drugs is recommended.[204]
The US Centers for Disease Control and Prevention (CDC) recommends hepatitis A vaccination for injection and non-injection drug users (i.e., all those who use illicit drugs).[206] The CDC also recommends universal hepatitis B vaccination in all adults aged 19 to 59 years.[206] In people 60 years of age or older, hepatitis B vaccination is recommended in the presence of additional risk factors, including current or recent injection drug use.[206]
The CDC recommends pre-exposure prophylaxis (PrEP) for HIV for adults and adolescents who inject drugs and report injection practices that place them at substantial ongoing risk of HIV exposure and acquisition (e.g., sharing needles).[203][204] The CDC also recommends consideration of post-exposure prophylaxis for HIV ≤72 hours after a potential exposure, including sharing of drug use equipment.[205] See Post-exposure HIV prophylaxis.
Psychosocial counselling and urine drug screen monitoring, as well as assessment and treatment of comorbid medical and psychiatric conditions (e.g., depression, anxiety disorders, and personality disorders), should occur as a part of maintenance therapy.[135] Drug therapy should be continued long term to prevent relapses.
People receiving chronic treatment with prescription opioids are 8- to 10-times more likely to initiate injection drug use, and so may benefit from enhanced efforts to prevent such initiation.[45]
Use of this content is subject to our disclaimer