Tapering: How to Safely Transition Off Opioid Pain Medications

Work closely with your healthcare providers to avoid withdrawal and keep your chronic pain under control.

 

Editor's Note: On April 9, 2019, just about 3 years after the CDC issued its guideline on prescribing opioids for chronic pain, setting off a whirlwind of opioid discontinuation and, in many practices, a halt to opioid prescribing, the FDA issued a safety communication noting that: "Health care professionals should not abruptly discontinue opioids in a patient who is physically dependent... Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms... (FDA) has received reports of serious harm in patients ... suddenly having these medicines discontinued or the dose rapidly decreased..." The very next day, CDC released its own followup which states that the CDC "does not endorse mandated or abrupt dose reduction or discontinuation" and that the CDC is "working diligently to evaluate the impact of the Guideline and clarify its recommendations."

This news may be too little, too late, for individuals who were successfully managing their chronic pain through opioid therapy. PPM will continue to udpate readers (follow us on Facebook; sign up for our free enewsletter) on this important and shifting healthcare topic. In the meantime, the following article offers some insight into how to safely transition off opioids when needed.

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Tapering off opioids to reduce physical dependence or side effects is a different phenomenon from tapering due to opioid addiction. For addicts, going off opioid pain medications can conjure images of Hollywood-style withdrawal symptoms — sweating, writhing in agony or overwhelming craving. The focus for these individuals is on avoiding withdrawal symptoms. But for individuals managing chronic pain through opioid therapy, the most common fear is that their pain will return when they taper off their medications. Because this kind of tapering involves a much lengthier process and includes transitioning to other treatments, it is driven by monitoring pain levels and withdrawal symptoms often don’t arise. (Read more about Opioid Use Disorder/Opioid Addiction at the end of this article).

There is a wide range of medical and non-medical therapies to help patients manage their pain. The key is to work with your healthcare providers to customize the right approach for you.

Opioids for Acute Pain

With acute pain, following surgery for example, a short course of opioids is often prescribed. If the duration of use is only a few days to a week or two, and the pain has resolved, this usually is not long enough for a patient to develop the physical dependence associated with withdrawal symptoms, according to Jennifer P. Schneider, MD, PhD, a recognized expert on addiction medicine, and pain management and an editorial advisor to PPM. For these patients, it’s not necessary to slowly taper off the medication.

In the event that it is necessary to taper off opioids afterpain has resolved, for example following knee replacement, a clinician will likely taper you quickly because all you have to be concerned about is withdrawal since you no longer have pain that needs to be managed, explains Dr. Schneider. Importantly, the withdrawal symptoms associated with opioids are not dangerous, often being described as flu-like, in contrast with some other drugs that can lead to death if stopped abruptly (eg, corticosteroids).

Opioids for Chronic Pain

The main consideration for chronic pain patients when tapering is their pain level. Ensuring that patients maintain an acceptable level of pain makes the tapering process for chronic pain much slower. “You have to do it more slowly – weeks, months, or even more than a year — because you have to see what happens to the pain level,” said Dr. Schneider. The duration of the taper is highly variable.

In addition, other pain management modalities are crucial and should be started before the taper begins. Without other treatments, patients can have increased pain as the drug is withdrawn. This can lead to patients abandoning the taper.

Source: 123RF

Smoothing the Transition: When You Stop Taking Opioids

There is a wide range of medical and non-medical options available to manage pain, which is why it’s so important to work closely with your healthcare team to find the right combination. For example, many patients living with chronic pain may also be dealing with anxiety and depression, and medications for these conditions can also affect pain levels. The treatment of anxiety and depression, and other behavioral or mental health issues, can help to minimize pain perception.

Ideally, patients should already be using other modalities to treat chronic pain, said Dr. Schneider. But often the focus is on medication. Other modalities include physical therapy, non-opioid drugs (such as gabapentin and pregabalin for neuropathic pain), cognitive behavioral therapy and counseling, among others.

Non-traditional methods can also be considered, such as acupuncture and hypnosis. “I think one of the most important things is that the patient needs to be engaged in order to be successful with weaning,” she says.

Courtney Kominek, PharmD, BCPS, CPE, agrees. “The bottom line is that patients need to be an active part of their pain management plan. It’s important to work on that patient-provider relationship to build trust.” Dr. Kominek is a clinical pharmacy specialist in pain management at the Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, and also a PPM editorial advisor.

It’s also important to understand that the tapering process is slow for a reason. “It just takes time for your body to readjust to the equilibrium right after we make a change,” explains Dr. Kominek. “When patients have been on these medications for a long time, it's going to take a long period of time to go off. But there is light at the end of the tunnel.”

Dr. Kominek also uses a range of modalities to help transition patients off opioid pain medication, including both non-opioid medications and non-pharmacologic approaches like home exercise, relaxation, meditation, and deep breathing). “I tell patients is that medications are just one piece of the pie.” She added that education is very important too. Patients need to understand what their diagnosis means for them and how pain is processed.

More on Opioid Use Disorder and Managing Opioid Addiction

Opioid use disorder (OUD), formerly termed opioid addiction, may include symptoms such as: taking more opioids than intended; craving opioids; and continuing use despite problems at home, work and school related to the drugs. OUD is separate from opioid physical dependence. Read more about the difference here.  Tapering off opioids may be conducted in those with OUD and those with physical dependence, but for different reasons.

The aim of opioid discontinuation — the term used for transitioning patients with OUD off opioids — is to minimize withdrawal symptoms and this can proceed quickly, according to both Drs. Kominek and Schneider.

Common early opioid withdrawal symptoms may include: agitation, anxiety, muscle aches, insomnia, runny nose, and sweating. Late symptoms of withdrawal may include: abdominal cramping, diarrhea, goose bumps, nausea, and vomiting.

Medication-assisted treatment (MAT) is one approach that is often used to help patients with OUD discontinue opioid use. MAT combines the use of medications specifically approved for the treatment of OMD, in combination with counseling and behavioral therapies. “We know that medication-assisted therapy provides lots of benefits for patients with opioid use disorder,” said Dr. Kominek.

Methadone, naltrexone, and buprenorphine are all indicated for the treatment of OUD. In May 2018, the FDA approved the first non-opioid treatment, lofexidine hydrochloride (Lucemyra), for the mitigation of withdrawal symptoms to facilitate abrupt discontinuation of opioids in adults.

Suboxone, a combined buprenorphine and naloxone treatment, is also used for MAT. However, according to Dr. Kominek, a patient must already be exhibiting withdrawal symptoms to be started on the drug. “This can be really scary for patients and they may not be willing to stop their opioid use,” she said.

Updated on: 04/25/19
Continue Reading:
Opioids: Addiction or Physical Dependence?
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