Opioid tapering

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Opioid tapering is the reduction of opioid doses over time. Opioid tapering is typically done in people taking opioids for chronic pain. Tapering may be conducted in medically-supervised inpatient or outpatient settings.

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Community-based opioid tapering increased after the 2016 "Center for Disease Control Guideline for Prescribing Opioids in Chronic Pain" was published, and many prescribers and organizations instigated opioid tapering practices in order to reduce opioid prescribing. [1] While the CDC guideline was intended to inform primary care physicians on new prescription initiation, in many cases it was misapplied beyond this narrow scope and used to inform opioid tapering practices among patients taking long-term prescription opioids for chronic pain.

Voluntary patient-centered opioid tapering has shown success with engagement and reduction of moderate and high-dose opioid doses over the course of months. [2] Principles of patient-centered opioid tapering include: patient consent to taper, patient ability to control the pace of the taper, and pause the taper if desired. Recent published national study protocols ascribe to these principles. [3]

Some healthcare providers have expressed concern about negative consequences of rapid forced tapering including suicidality. [4] [5] Human Rights Watch has called the negative consequences of forced prescription opioid tapering in chronic pain to be a "human rights issue". [6]

In April 2019, the Federal Drug Administration issued a drug safety communication warning against sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. [7] In October 2019, U.S. Health and Human Services published the HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. [8] The document calls for a patient-centered approach, cautions against a blanket assumption that less opioids is always best, and provides an implementation guide for opioid tapering for patients for whom reduction is best.

Benefits

Some studies show pain improves with tapering of long terms opioids, though these are generally data from studies conducted in inpatient settings or in intensive and interdisciplinary programs [9] that are largely inaccessible to the vast majority of patients taking opioids. One community-based opioid tapering study reported that on average pain remained constant among a group of patients tapering long-term opioids, but the study was voluntary and those not wishing to taper either did not enroll or dropped out of the study. [10] The authors cautioned against generalizing their findings to patients who do not wish to taper opioids. Authors of a VA review on "Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain" recently concluded that: "... evidence is inadequate to fully weigh the balance of the benefits and harms of long-term opioid therapy against the benefits and harms of tapering, primarily due to limited information on tapering harms." [11]

Iatrogenic harms

Some healthcare providers have expressed grave concern about iatrogenic consequences from rapid forced tapering, and poor tapering practices, including suicidality and patient suicides. [12] Data suggest that opioid dose variability—either increases or decreases in dose—confers risk for opioid overdose. [13] Retrospective evidence suggests that rapid tapers are associated with increased emergency department visits and hospitalizations. Cautions have been raised for conducting opioid tapering in patients with mental health conditions such as major depression and post-traumatic stress disorder as opioid tapering may destabilize these vulnerable patients and expose them to new health risks. Tapering in veterans has been associated with increased risk for overdose and suicide. [14] Authors of this report cautioned that tapering should be conducted in select patients and with careful monitoring that ends at least 3 months after the taper. In 2021, researchers published a report in JAMA that citing iatrogenic harms of opioid tapering -- including overdose and mental health crises -- among patients receiving high dose prescription opioids. [15] One criticism of current tapering research is that attrition from studies is not characterized, thereby potentially undercounting patients who have lost their medical care or suicided during tapering. [16]

Related Research Articles

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Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid agonist used for chronic pain and also for opioid use disorder. It is used to treat chronic pain, and it is also used to treat addiction to heroin or other opioids. Prescribed for daily use, the medicine relieves cravings and removes withdrawal symptoms. Withdrawal management using methadone can be accomplished in less than a month, or it may be done gradually over a longer period of time, or simply maintained for the rest of the patient’s life. While a single dose has a rapid effect, maximum effect can take up to five days of use. After long-term use, in people with normal liver function, effects last 8 to 36 hours. Methadone is usually taken by mouth and rarely by injection into a muscle or vein.

<span class="mw-page-title-main">Naloxone</span> Opioid receptor antagonist

Naloxone, is a medication used to reverse or reduce the effects of opioids sold under various brands. It is used to counter decreased breathing in opioid overdose. Effects begin within two minutes when given intravenously, and within five minutes when injected into a muscle. The medicine can also be administered by spraying it into a person's nose. Naloxone blocks the effects of opioids for 30 to 90 minutes. Multiple doses may be required, as the duration of action of some opioids is greater than that of naloxone. Emergency medical services data from Massachusetts found that 93.5% of people given naloxone survived their overdose.

<span class="mw-page-title-main">Gabapentin</span> Anticonvulsant medication for seizures and pain

Gabapentin, sold under the brand name Neurontin among others, is an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain. It is commonly used medication for the treatment of neuropathic pain caused by diabetic neuropathy, postherpetic neuralgia, and central pain. It is moderately effective: about 30–40% of those given gabapentin for diabetic neuropathy or postherpetic neuralgia have a meaningful benefit.

<span class="mw-page-title-main">Opioid</span> Psychoactive chemical

Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use disorder, reversing opioid overdose, and suppressing cough. Extremely potent opioids such as carfentanil are approved only for veterinary use. Opioids are also frequently used non-medically for their euphoric effects or to prevent withdrawal. Opioids can cause death and have been used for executions in the United States.

<span class="mw-page-title-main">Opioid use disorder</span> Medical condition

Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are important components of opioid use disorder.

<span class="mw-page-title-main">Buprenorphine</span> Opioid used to treat pain & opioid use disorder.

Buprenorphine, sold under the brand name Subutex among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection, as a skin patch (transdermal), or as an implant. For opioid use disorder, it is typically started when withdrawal symptoms have begun and for the first two days of treatment under direct observation of a health-care provider.

<span class="mw-page-title-main">Cyclobenzaprine</span> Muscle relaxant medication

Cyclobenzaprine is a muscle relaxer used for muscle spasms from musculoskeletal conditions of sudden onset. It is not useful in cerebral palsy. It is taken by mouth. Use is not recommended for more than a few weeks.

<span class="mw-page-title-main">Dextropropoxyphene</span> Withdrawn opioid medication

Dextropropoxyphene is an analgesic in the opioid category, patented in 1955 and manufactured by Eli Lilly and Company. It is an optical isomer of levopropoxyphene. It is intended to treat mild pain and also has antitussive and local anaesthetic effects. The drug has been taken off the market in Europe and the US due to concerns of fatal overdoses and heart arrhythmias. It is still available in Australia, albeit with restrictions after an application by its manufacturer to review its proposed banning. Its onset of analgesia is said to be 20–30 minutes and peak effects are seen about 1.5–2.0 hours after oral administration.

<span class="mw-page-title-main">Polypharmacy</span> Use of five or more medications daily

Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions. Most commonly it is defined as regularly taking five or more medicines but definitions vary in where they draw the line for the minimum number of drugs. Polypharmacy is often the consequence of having multiple long-term conditions, also known as multimorbidity. An excessive number of medications is worrisome, especially for older patients with many chronic health conditions, because this increases the risk of an adverse event in those patients.

<span class="mw-page-title-main">Lubiprostone</span> Medication used for constipation

Lubiprostone, sold under the brand name Amitiza among others, is a medication used in the management of chronic idiopathic constipation, predominantly irritable bowel syndrome-associated constipation in women and opioid-induced constipation. The drug is owned by Mallinckrodt and is marketed by Takeda Pharmaceutical Company.

<span class="mw-page-title-main">Opioid overdose</span> Medical condition

An opioid overdose is toxicity due to excessive consumption of opioids, such as morphine, codeine, heroin, fentanyl, tramadol, and methadone. This preventable pathology can be fatal if it leads to respiratory depression, a lethal condition that can cause hypoxia from slow and shallow breathing. Other symptoms include small pupils, and unconsciousness, however its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including permanent brain damage.

Neonatal withdrawal or neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) is a withdrawal syndrome of infants after birth caused by in utero exposure to drugs of dependence, most commonly opioids. Common signs and symptoms include tremors, irritability, vomiting, diarrhea, and fever. NAS is primarily diagnosed with a detailed medication history and scoring systems. First-line treatment should begin with non-medication interventions to support neonate growth, though medication interventions may be used in certain situations.

In the United States, prescription monitoring programs (PMPs) or prescription drug monitoring programs (PDMPs) are state-run programs which collect and distribute data about the prescription and dispensation of federally controlled substances and, depending on state requirements, other potentially abusable prescription drugs. PMPs are meant to help prevent adverse drug-related events such as opioid overdoses, drug diversion, and substance abuse by decreasing the amount and/or frequency of opioid prescribing, and by identifying those patients who are obtaining prescriptions from multiple providers or those physicians overprescribing opioids.


Methadone maintenance treatment (MMT) utilizes methadone to treat dependence on heroin or other opioids, and is administered on an ongoing basis. Methadone is an opioid agonist that binds to the same receptors in the brain as heroin and other opioids. MMT is administered with the objective of relieving withdrawal symptoms. Higher doses of methadone may cause respiratory depression and/or euphoria in some patients. Methadone maintenance reduces the cravings for other opioids, and reduces the risk of fatal overdose from street drugs since the purity and strength of methadone is known, whereas substances obtained from the street vary significantly in strength and purity. Methadone maintenance has been termed "a first step toward social rehabilitation" because it increases the retention of patients in treatment, relieves them from the need to find, buy, and use multiple daily doses of street opioids, and offers a legal medical alternative.

<span class="mw-page-title-main">Deprescribing</span> Medical condition

Deprescribing is described as a patient-centred process to taper or stop medications with the intention to achieve improved health outcomes by reducing exposure to medications that are potentially either harmful or no longer required. Deprescribing is important to consider with changing health and care goals over time, as well as polypharmacy and adverse effects. Deprescribing can improve adherence, cost, and health outcomes but may have adverse drug withdrawal effects. More specifically, deprescribing is the planned and supervised process of intentionally stopping a medication or reducing its dose to improve the person's health or reduce the risk of adverse side effects. Deprescribing is usually done because the drug may be causing harm, may no longer be helping the patient, or may be inappropriate for the individual patient's current situation. Deprescribing can help correct polypharmacy and prescription cascade.

<span class="mw-page-title-main">Opioid epidemic in the United States</span> Ongoing overuse of opioid medication in the US

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<span class="mw-page-title-main">Beth Darnall</span> American scientist, pain psychologist, author and Associate Professor in Stanford University

Beth Darnall is American scientist, pain psychologist, author, and Associate Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University where she directs the Stanford Pain Relief Innovations Lab. From 2005 to 2012, Darnall was an assistant professor and associate professor at Oregon Health & Science University.

<span class="mw-page-title-main">Opioid epidemic</span> Deaths due to abuse of opioid drugs

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<span class="mw-page-title-main">Prescription drug addiction</span> Medical condition

Prescription drug addiction is the chronic, repeated use of a prescription drug in ways other than prescribed for, including using someone else’s prescription. A prescription drug is a pharmaceutical drug that may not be dispensed without a legal medical prescription. Drugs in this category are supervised due to their potential for misuse and substance use disorder. The classes of medications most commonly abused are opioids, central nervous system (CNS) depressants and central nervous stimulants. In particular, prescription opioid is most commonly abused in the form of prescription analgesics.

References

  1. ↑ "CDC Guideline for Prescribing Opioids in Chronic Pain". MMWR. Recommendations and Reports. 65. 2016. doi: 10.15585/mmwr.rr6501e1er . PMC   6390846 .
  2. ↑ Darnall, Beth D.; Ziadni, Maisa S.; Stieg, Richard L.; Mackey, Ian G.; Kao, Ming-Chih; Flood, Pamela (2018-05-01). "Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain". JAMA Internal Medicine. 178 (5): 707–708. doi:10.1001/jamainternmed.2017.8709. ISSN   2168-6106. PMC   5876887 . PMID   29459978.
  3. ↑ Darnall, Beth D.; Mackey, Sean C.; Lorig, Kate; Kao, Ming-Chih; Mardian, Aram; Stieg, Richard; Porter, Joel; DeBruyne, Korina; Murphy, Jennifer; Perez, Luzmercy; Okvat, Heather (2019). "Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol". Pain Medicine. 21 (8): 1523–1531. doi: 10.1093/pm/pnz285 . PMC   7530567 . PMID   31876947.
  4. ↑ Darnall, Beth D. (2018). "International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering". Pain Medicine. 20 (3): 429–433. doi:10.1093/pm/pny228. ISSN   1526-2375. PMC   6657573 . PMID   30496540.
  5. ↑ "FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering". U.S. Food and Drug Administration. 20 December 2019. Retrieved 4 October 2020.
  6. ↑ "Not Allowed to Be Compassionate" (PDF).
  7. ↑ "FDA safety communication on opioid tapering". FDA. 2019-07-17.
  8. ↑ "HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics" (PDF). U.S. Health and Human Services. October 2019.
  9. ↑ Murphy, Jennifer L.; Clark, Michael E.; Banou, Evangelia (February 2013). "Opioid Cessation and Multidimensional Outcomes After Interdisciplinary Chronic Pain Treatment". The Clinical Journal of Pain. 29 (2): 109–117. doi:10.1097/AJP.0b013e3182579935. ISSN   0749-8047. PMID   22751033. S2CID   22571965.
  10. ↑ Darnall, Beth D.; Ziadni, Maisa S.; Stieg, Richard L.; Mackey, Ian G.; Kao, Ming-Chih; Flood, Pamela (2018-05-01). "Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain". JAMA Internal Medicine. 178 (5): 707–708. doi: 10.1001/jamainternmed.2017.8709 . ISSN   2168-6106. PMC   5876887 . PMID   29459978.
  11. ↑ "Management Briefs eBrief-no166 --". www.hsrd.research.va.gov. Retrieved 2020-01-11.
  12. ↑ Darnall, Beth D. (2018). "International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering". Pain Medicine. 20 (3): 429–433. doi:10.1093/pm/pny228. ISSN   1526-2375. PMC   6657573 . PMID   30496540.
  13. ↑ Glanz, Jason M.; Binswanger, Ingrid A.; Shetterly, Susan M.; Narwaney, Komal J.; Xu, Stan (2019-04-05). "Association Between Opioid Dose Variability and Opioid Overdose Among Adults Prescribed Long-term Opioid Therapy". JAMA Network Open. 2 (4): e192613. doi:10.1001/jamanetworkopen.2019.2613. PMC   6481879 . PMID   31002325.
  14. ↑ Oliva, EM (March 2020). "Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation". British Medical Journal. 368: m283. doi:10.1136/bmj.m283. PMC   7249243 . PMID   32131996.
  15. ↑ Agnoli, A (August 3, 2021). "Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids". JAMA. 326 (5): 411–419. doi:10.1001/jama.2021.11013. PMC   8335575 . PMID   34342618.
  16. ↑ Darnall, BD (August 9, 2021). "Clinical and neuroscience evidence supports the critical importance of patient expectations and agency in opioid tapering". Pain. 163 (5): 824–826. doi:10.1097/j.pain.0000000000002443. PMC   9009317 . PMID   34382602. S2CID   236989543.
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