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HHS New Clinical Guide Supports Concerns Over Abrupt Discontinuation and Tapering of Opioids

October 16, 2019
Yet another policy shift around best practice for avoiding opioid withdrawal and reducing risk for patients on chronic opioid therapy.

Nearly four years after the CDC published its opioid prescribing for chronic pain guideline, the US Department of Health and Human Services (HHS) has published a clinician guide on “Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics” that not only answers questions weighing on the minds of primary care doctors, but which also supports what pain specialists have been saying all along: there are risks to rapid opioid tapers and abrupt opioid discontinuation. The guide comes after a Spring 2019 FDA safety communication on the same topic.

The new HHS guide provides advice for clinicians who may be considering, or initiating, changes in a patient’s opioid dosage. “In each case the clinician should review the risks and benefits of the current therapy with the patient and decide if tapering is appropriate based on individual circumstances,” the guide reads.

It is well accepted that patients benefit from opioids only when the benefit of using them outweighs their risks. However, for long-term opioid therapy, abrupt changes in the patient’s regimen may be harmful; the tapering process requires both a thorough case review and a comprehensive discussion with the patient. “HHS does not recommend opioids be tapered rapidly or discontinued suddenly due to the significant risks of opioid withdrawal, unless there is a life-threatening issue confronting the individual patient,” the HHS announced in a press release accompanying the guide.1

The guide builds on previously published guidelines – including the 2016 CDC guideline noted above and the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain – but digs deeper into current thinking on opioid discontinuation and tapering. In addition to including patients in the decision-making process around opioid therapy, clinicians are specifically encouraged to consider treatment needs for managing opioid withdrawal symptoms, including behavioral health support when depression, anxiety, or post-traumatic stress disorder (PTSD) factor in.

The guide goes into detail on opioid tapering, noting that plans should be individualized, with common tapers involving dose reductions of 5 to 20% every 4 weeks, and features an opioid tapering flowchart that may help clinicians to weigh risks and benefits. HHS also points out in the guide that clinicians should “avoid dismissing patients from care” as this practice “puts patients at high risk and misses opportunities to provide life-saving interventions, such as medication-assisted treatment (MAT).” This point should have a large impact on clinicians and practices that have turned opioid users away over the past few years out of fear of being scrutinized for opioid prescribing. There is, in fact, an HHS call to “ensure that patients continue to receive coordinated care,” with the agency stating that “risks to noncollabortive tapering” do indeed exist—again, a message that pain specialists have been iterating since the US opioid crisis was declared.

Finally, the guide addresses unique challenges that may occur when discontinuing or tapering a patient from opioids, such as the development of opioid use disorder (OUD) or worsened pain. The guide calls out buprenorphine as a potential alternative opioid treatment in the latter case, as the drug has been shown to treat both pain and OUD. See PPM’s recent report on the partial opioid agonsist: Buprenorphine: A Promising Yet Overlooked Tool. Interested practitioners may also wish to consider taking the AAAP's 8-hour buprenorphine/MAT waiver course, which includes a solid overview of addiction medicine.

Overall, HHS is promoting that, “Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” Adm. Brett P. Giroir, MD, Assistant Secretary for Health at the HHS, said in the press release. For PPM readers, this may seem like an “about time” moment although, certainly, more work is needed to reduce misconceptions around opioid therapy in pain management.

The full guideline can be found here. See PPM Reader Richard Lawhern's take on the new guideline.

Last updated on: October 21, 2019
Continue Reading:
HHS Inter-Agency Task Force Urges New Ways to Limit Opioid Use and Addiction
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