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Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain

Interview with Jordan L. Newmark, MD, clinical assistant professor in the Division of Pain Medicine and, by courtesy, Addiction Medicine, and associate division chief of education at Stanford University School of Medicine.
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In a patient with chronic pain who develops an opioid use disorder (OUD), what factors go into the decision of whether or not to wean the patient off opioids?

Dr. Newmark offers strategies for weaning patients off opioids.Jordan L. Newmark, MD

Dr. Newmark: In patients with an OUD, overdose or toxicity as the most major concern, a number of monitoring tools exist to help reduce the risk for these serious consequences. Keep in mind that none of these tools are flawless, therefore sound clinical judgment, combined with the principle of “safety first,” is essential in caring for these patients. Also, having a low threshold for seeking consultation from an addiction medicine specialist for comanagement is important to consider.  

The first tools are state prescription drug monitoring programs (PDMPs). Checking the PDMP every time you see a patient while on opioid therapy is essential. If the patient simultaneously received an opioid prescription from another physician without clear and reasonable purposes (for example, after a surgical procedure), this may signal aberrancy, and the need to either wean or stop prescribing.

The second tool is the 4 A’s screening tool (analgesia, activities of daily living, adverse effects, and aberrant drug-related behaviors),1 which helps determine whether the benefit of continued opioid use outweighs the risk in the chronic pain population. If a patient is determined to be at higher risk for adverse effects, consideration should be made to reduce the opioid dose or wean treatment. Also, if a patient is not showing improved function, but is showing side effects—such as sedation or aberrant drug taking—consideration should be given to lower the dose or wean treatment.

In contrast, if the patient is treatment adherent and functioning well, this may suggest that opioid treatment is effective, and consideration should be given to continue treatment as long as that benefit outweighs any potential risks found.

A third tool is called the 4 C’s (see Managing Opioid Use Disorders and Chronic Pain), which can be used to screen for a substance use disorder.2 If the patient has an OUD, presumably, he or she will answer yes to 1 of the 4 C’s.

Finally, in-office pill counts and urine drug testing help ensure the patient is taking prescribed opioids on time and as scheduled, and is not taking any other unexpected substances. These safety checks help protect the patient from harm, and protect the physician as well. However, none of these tools are perfect. Recognizing both their benefits and potential weaknesses will allow you to make the best clinical decisions for your patient.

Optimally, patient expectations should be set up-front, before opioid therapy is initiated. I tell patients, “You are going be monitored while you are on the medication. We will ask you about your function and want to make sure you meet certain goals, such as increasing physical activity. If you are not meeting those goals, then the dose needs to be adjusted such that your goals are met, because we do not want to expose you to the potential risks of chronic opioid therapy for no benefit to yourself.”

If this conversation has not occurred, or you are seeing a new patient who comes to you already taking chronic opioid therapy, risk management is a little more challenging. However, at the end of the day, try to align the patient’s goals with your goals, which should be to improve function and quality of life.

What do you do if the patient is unhappy with your decision to reduce the dose or wean from opioids?

Dr. Newmark: When delivering the message, you need to take a moment to breathe, and put on your “breaking-bad-news hat,” which was taught to you in medical school. This reminds you to be empathetic with the patient. Preliminary, unpublished simulation-based research I conducted with my colleagues indicates that if you exhibit empathy and communicate clearly with the patient about your concerns and why you are making a treatment change, usually, the patients will align with your goal and be satisfied with that treatment alteration.

This was a surprising research finding. I would have thought that giving the patient what he or she asked for (ie, more opioids) at least in a simulated environment, would have led to higher patient satisfactions scores as well as higher prescribing rates. Instead, I found the exact opposite, with clinicians in a simulated environment who were more restrictive with opioid prescribing and did the most monitoring actually ending up communicating better, having safer prescribing patterns, and the simulated patients thought that those were the most satisfying interactions.

While these conversations can be anxiety-provoking, with practice, the patient is not likely to get upset. Again, the bottom line is that you have to keep yourself and the patient safe, no matter what.

Another strategy is to align the patient’s family members and friends with the goals of treatment, so that they can secondarily sell the patient on the idea of reducing or stopping the opioid dose down the road, should that be warranted. Often patients need time to think over and process your conversation, and then may agree with the treatment change.

What is the optimal weaning strategy for those patients for whom weaning is considered the best choice?

Dr. Newmark: The optimal strategy depends on the degree of aberrancy. If the patient is engaging in high-risk behaviors that put him or her at risk for overdose, the patient should be weaned aggressively. And what do I mean by that? This is more of an art than a science. In general, I would probably wean over a less than 2- or 3-week time frame, and give patients adjuvant treatments, such as gabapentin for pain, clonidine for pain and withdrawal symptoms, ondansetron for withdrawal symptoms, and loperamide for diarrhea.

Last updated on: March 17, 2017
Continue Reading:
Opportunities and Challenges of Pain Management: The Family Physician’s Perspective
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