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A Plea for Proper Opioid Tapering

Editor's Memo July/August 2017
Page 1 of 2

It wasn’t long after the opioid guidelines from the Centers for Disease Control and Prevention (CDC)1 were released in 2016 that I began to hear rumors about pain patients being cut off from opioids and then committing suicide. I initially didn’t take these reports seriously, since the CDC guidelines neither placed a ceiling on opioid dosages nor required that patients be “cut off” of opioids.

But as I noted in a previous Editor’s Memo: a survey of 1,978 chronic pain patients found that 68% said their opioid medication had been decreased or stopped since the CDC adopted its prescribing guidelines.2 In addition, 45% of respondents were warned by their doctors that additional decreases would be necessary. Most striking, just over 50% said they had considered suicide as a way to end their pain.2

I also thought that physicians who prescribed opioids were familiar with the need for a safe and effective opioid weaning strategy that balances slow medication step-down with the management of symptoms of withdrawal. Although uncomfortable, supervised withdrawal from opioids should not be life-threatening.3-5 Because there are no formal guidelines on opioid tapering, Practical Pain Management interviewed Jordan L. Newmark on his strategies for weaning opioids in the March 2017 issue.6 Unfortunately, despite knowledge about safe tapering being available, reports of patient suicides and other tragedies due to improper opioid reduction have continued, so safety concerns about opioid tapering are an urgent matter.7

Safe and effective opioid weaning practice is really necessary.

Risk of Improper Weaning

My concern elevated a few months ago when I received a telephone call from a physician–pain specialist who represented a major insurance company. He was going to give me advice “peer to peer” on opioid tapering since his insurance company was demanding that every pain patient on morphine milligram equivalents (MME) over 90 mg a day be on a taper program.

The insurance company’s rationale was that the CDC recommended a maximal dosage of 90 MME meant that every patient above this level should reduce their opioid dosage to this level. Note that this is not what was called for in CDC guidelines. The 90 MME standard, as written in the guidelines, applies to primary, not specialty, care, and calls for evaluation and justification for dosage above this level—it is not a “ceiling” or maximal dosage. Rather, the CDC guidelines state: “Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.”

Unfortunately, his company’s taper program called for every patient receiving over 90 MME to immediately have their opioid dosage cut in half (50%), with another 25% reduction within 2 weeks. Perhaps the insurance company’s pain specialist was well-meaning and sincere, but he clearly needed to be educated about the difference between detoxifying an addict and tapering a pain patient. I kindly informed him that he was preaching a dangerous regimen that I would not follow.

Assess, Document, Repeat

When do the risks outweigh the benefits? Reasons for potentially discontinuing a medication, as cited by the CDC, include:

  • When a patient reports a lack of improvement in pain or function
  • Signs of opioid abuse, nonadherence, and/or severe adverse effects
  • Unexpected and confirmed results on urine drug tests

As noted first, the decision to decrease the dose has to be based not on the patient’s dose, but rather on the patient’s pain relief and function. If a patient is stable on the dose and functioning well, and this has been specifically documented in the chart, repeatedly, then any decision to taper the dose must be considered carefully. It may be reasonable to consider an initial taper, but it’s important to assess and document the outcome. If the patient’s pain and function worsen, then decreasing the prior dose may not be in the patient’s best interest.

In order to justify maintaining the current dose for a new patient, it’s important to do a thorough initial evaluation (including obtaining old records, a history of the pain problem, and details of prior and current treatments; asking about personal and family history of drug addiction or abuse; focused physical exam and imaging studies if appropriate; urine drug test, checking the Prescription Drug Monitoring Program [PDMP] or CURES website; document treatment goals, including functional goals; etc).

In this issue of PPM, my colleagues and I have written a review of justifications for existing patients who require greater than 90 MME. Although the initial office visit may be long past, physicians still have to be sure there is:

Last updated on: August 16, 2017
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