Knowing When to Say When: Transitioning Patients from Opioid Therapy


Uses a case study to teach when and how to taper and/or transition patients off opioid-based medications in primary care settings.

Resource Materials


Developer: University of Massachusetts Medical School (Massachusetts Consortium)

Curriculum resource type: Case-based learning (CBL)

Method used: Case-based module

Intended audience: Primary care physicians and physicians-in-training

Implementation time: 2 hours

Additional components: Student materials; facilitator guide

Educational objectives:

  • Describe aberrant drug-taking behaviors that may indicate opioid medication misuse and how to respond to these behaviors effectively in outpatient practice
  • Describe strategies for monitoring patients who are prescribed opioids for signs of misuse of those medications
  • Using a risk-benefit framework, describe conditions under which discontinuation of opioids may be considered
  • Describe strategies for transitioning patients off of opioids and how to treat opioid withdrawal symptoms
  • Discuss options for specialty addiction treatment for patients with chronic pain including inpatient detoxification and opioid agonist modalities
  • Discuss management of problematic behaviors that may arise when discontinuing opioids including declining to transition, drug abuse, disruptive or threatening behavior, and suicidality
  • Discuss the principle of “abandonment” and list the steps that should be taken to minimize medico-legal risk when discontinuing opioid treatment

Curriculum resource description: This educational module teaches medical providers how to recognize and manage problematic behaviors that sometimes arise in patients taking prescription opioids, including selling medication, using medications in ways other than prescribed, and refusing to comply with random drug screens or pill counts. Strategies for how to recognize when safety is compromised and when drug misuse or diversion is occurring are described. The module covers how to taper patients off of opioids, treat opioid withdrawal symptoms, and transition patients to more structured or alternative types of care when necessary. In addition, it describes how to manage behaviors that may arise when discontinuing opioids such as disruptive or threatening behavior.

This case study module is designed for use by a facilitator with a small group of practicing primary care providers or physicians-in-training. In this module, participants discuss the care of a patient with low back pain who has been treated for than a year with prescription opioids. The case study contains background material and information about two office visits that take place 8 weeks apart. Participants are also given supporting materials, including a list of commonly used screening tools, urine drug testing information, a list of medications used to ease withdrawal symptoms, and a model letter for discontinuation of opioid treatment. The facilitator guide contains questions designed to stimulate discussion on how best to care for patients and ensure appropriate administration of opioid medications.

Key words: Drug abuse; drug addiction; substance use disorder; opioids; chronic pain