Tapering Chronic Pain Patients Off of Opioids
Presentation by Chantal Berna, MD
With the growing concern about misuse and abuse of opioids, it may be prudent to review the treatment plan of noncancer patients on long term opioids, with the goal of tapering them off when possible.
That was the message that Chantal Berna, MD, instructor at the University Hospital of Lausanne, Switzerland, gave to attendees of the World Congress of the World Institute of Pain in New York City, May 29, 2016.
The Centers for Disease Control and Prevention has called opioid overdose an epidemic, citing a 200% increase in overdose deaths involving opioids (prescription opioids and heroin) since 2000.1 In 2014, two million people abused or were dependent on opioids.
Nonetheless, there’s reluctance to taper patients off of prescription opioids. According to a study of veterans, of more than 550,000 who are on long-term opioid therapy (defined as more than 3 months), only 7.5% had discontinued opioids when measured a year after they started taking the drugs.2
Yet the support for long-term use of opioids is minimal, according to Dr. Berna. “There’s very low evidence for chronic opioid therapy in noncancer pain management,” she said. Most “long-term” trials are less than 4 months with doses at less than or equal to 180 mg of morphine equivalents.
A Cochrane review included 26 studies that were longer than 6 months, with only 1 study being a randomized clinical trial. Most had a high dropout rate, with an average of 23% leaving the study because of adverse events. The meta analysis found weak evidence that patients experienced clinically significant pain relief and inconclusive evidence regarding quality of life and functional improvements.3
The lack of long-term randomized trials is one of economics, note many pain experts. Most premarketing studies are funded by the pharmaceutical industry, but once a drug has been approved, there is little incentive for the companies to conduct head-to-head trials. This may be changing, however, due to increased pressure by government agencies to show long-term efficacy and the introduction of Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to ensure that the benefits of a drug or biological product outweigh its risks.4
Opioid Benefits Over Time?
Over the long term, the benefits of opioids may diminish. Dr. Berna pointed to studies showing that patients on long-term opioids did equally well or better when the opioids were tapered.5 “It makes you wonder whether there are benefits when people have been on opioids for more than 3 or 4 months,” she said.
The risks of long-term use, however, are clear. Adverse events associated with long-term use include sedation, decreased concentration and memory, drowsiness, changes in mood, hormonal changes that can lead to osteopenia, constipation, dry mouth, abdominal pain, nausea, and sexual dysfunction.6 Higher doses of opioids, such as more than 100 mg or 120 mg of morphine equivalent, correlate with increased risk of overdose death, suicide, complications like fractures, interference in day-to-day activities, depression, and an increased risk of addiction, according to Dr. Berna. “A lot of people think that maybe the benefits are not outweighed by the risks,” she said.
Who May Benefit From Tapering?
The ideal patient for long-term use may be rare: This patient has good coping skills, uses other therapies to help cope with pain, such as exercise, relaxation, and meditation, and has good social support. “Many patients have less desirable characteristics,” said Dr. Berna. Some signs that tapering might be recommended include negative mood, poor coping strategies, poor pain control or functioning, and the use of opioids to cope with other issues like stress and mood, she added.
Physicians should consider a taper when patients get poor pain relief or functioning despite reasonable increases in dose, significant adverse effects, not adhering to treatment recommendations, deterioration in functioning, or if their underlying condition causing the pain improves.
Research is fairly limited on the best way to taper, and few guidelines to assist physicians exist. But how fast you taper depends on how long the patient has been on opioids, the dose, and the number of medications the patient is taking, noted Dr. Berna.
If the patient is on multiple opioids, start with longer acting opioids, like oxycodone, first. “After years of treatment, most patients are quite uncertain if this component of their treatment is still working. They are, however, intensely aware of the immediate relief from their short acting opioid, and tend therefore to hang on to that component longer,” sais Dr. Berna.
Therefore, starting with the easiest to let go of can give the patient a sense of success. She advises physicians to decrease by 10% to 20% of the original dose every 5 to 7 days until the patient is at 30% of the original dose. Then decrease by 10% of remaining dose every week.
It has been shown that by using this protocol, withdrawal symptoms can be greatly minimized. If the patient has been on opioids for more than 2 years, however, then you may need to wait as long as a month between tapers, rather than a week, noted Dr. Berna. Chronic pain patients may need to taper slowly so they have time to build in other strategies for living with pain.
Cognitive behavioral therapy (CBT) and interdisciplinary approaches in patients with chronic pain may be needed, and psychological support is recommended to help cope with anxiety that may arise related to the taper, increase in depression, and poor strategies for coping with pain.
Patients who are not slowly tapered may experience withdrawal symptoms, including a temporary increase in pain, hypertension, tachycardia, restlessness, sweating, gastrointestinal symptoms (nausea, cramping and diarrhea), tremor, anorexia, dizziness, hot flashes, shivering, cold symptoms, insomnia, anxiety, and mood swings.
Symptoms typically start about 2 to 3 half-lives after the last dose and improve within 1 to 2 weeks. Secondary abstinence syndrome, characterized by general malaise, fatigue, decreased well-being, poor tolerance to stress, and craving for opioids, can last for up to 6 months. Educating patients about expected symptoms and pain outcomes might help alleviate anxiety.
Some symptoms can be managed with alpha-adrenergic agonists, such as tizanidine, a muscle relaxant, or the antihypertensive agents—clonidine, guanfacine, and lofexie. Depression may need to be addressed with antidepressants and other modalities.6
Based on the evidence, patients often experience stable or improved pain relief after tapering.6 But physicians should continue to manage non-opioid therapies and promote an interdisciplinary approach to pain.