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10 Articles in Volume 17, Issue #6
A Plea for Proper Opioid Tapering
Centers of Excellence in Pain Management: Past, Present, and Future Trends
Comorbid Pain and Childhood Obesity
Discussing Migraine With Your Patients: A Common Sense Guide for Clinicians
Justification of Morphine Equivalent Opioid Dosage Above 90 mg
Letters to the Editor: Dependence vs Addiction, Opioid Metabolism
Opioid Rotation From Opana ER Following FDA Call for Removal
Psoriatic Arthritis: Established, Newer, and Emerging Therapies
Sleep-Wake Disorders and Chronic Pain: Reciprocal and Interactive Effects
What are Nav1.7 inhibitors and how are they used in the treatment of neuropathic pain?

A Plea for Proper Opioid Tapering

Editor's Memo July/August 2017

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:

  • Ongoing risk assessment, which includes attention and action on red flags; random urine drug tests (and documentation of any action taken on unexpected results); and checking the state’s PDMP (CURES in California) websites
  • Documentation of the patient’s functioning on each visit (not just a number from 1 to 10, but rather specific activities, time in bed, etc) to provide ongoing evidence of benefit of the treatment or lack thereof
  • Attention to anxiety, depression, trauma, and other psychological issues (don’t write them off as just “expected” in a patient with pain), with referrals to psychologist, therapist, or psychiatrist if indicated, which may result in psychotherapy and/or psychotropic medications
  • Recommendation and follow-up of other modalities such as physical therapy (and this includes not only PT clinic visits but an ongoing home exercise program); nonopioid medications; complementary approaches such as massage, acupuncture, etc
  • Consultation referral, if potentially helpful, to a specialist such as a rheumatologist, physiatrist, neurologist, interventional pain specialist for injections and other procedures, orthopedic surgeon, noninterventional pain specialist, etc

Patient willingness to engage in their treatment, although often ignored, is very important. Lack of willingness can often be remedied only with help from a behavioral health specialist, who can address the obstacles in the patient’s path. This approach will not only be in the patient’s best interest but will provide the practitioner with plenty of justification for continuing the current treatment approach and dose.

How to Wean

Tapering opioids in pain patients is a very different process than detoxifying opioid addicts, and often takes a lot longer (several months vs several weeks), depending on the dose they begin with and the extent of their pain. The rate of detoxifying addicts is driven only by the need to prevent withdrawal; there are standard protocols, and adding clonidine and other medications (such as gabapentinoids, antidepressants, antinausea medications, etc) can help mitigate withdrawal symptoms.

However, it cannot be emphasized enough that tapering or weaning pain patients are a more complicated and longer process, whose timing depends on pain response and the need to introduce alternative pain modalities. The modalities should be in place before the taper begins, and the percent decreased and the frequency depends on how the pain has responded to the combination of other modalities and the decrease in analgesia from the opioid. It is important to recognize that concurrent behavioral health modalities are also often needed.

It has been my clinical experience that severe chronic pain patients on long-term opioids should never be on a tapering schedule that exceeds about 5% a week. Why? If the opioid dosage is reduced too quickly, the pain may re-emerge and flare at the same time withdrawal symptoms occur. The combination of a severe pain flare and opioid withdrawal symptoms can be deadly.7

Tragic, documented cases of inhumane stoppage of opioids continue to be reported, indicating that the anti-opioid war may have gone too far. For example, a few weeks ago, I was contacted by the family of a US Army veteran, a highly decorated, combat Ranger, who had just been totally cut off of opioids, with no tapering at all. Twenty years ago he had suffered a stroke, which had created a classic, central pain syndrome (Dejerine-Roussy). He had been maintained and functioned well on 50 mg of methadone and 20 mg of diazepam a day. At his regularly scheduled VA hospital appointment, he was told, in writing (I saw the note), that his VA hospital was stopping all opioids because acupuncture, massage, and behavioral cognitive therapy were safer and superior. They sent him home with no opioids or symptomatic withdrawal medications. Once seen by my office, he was quickly reinstated on his previous methadone and diazepam dose and perked right up.

Dangerous tapering and sudden stoppage of opioids are clearly evident in some locales, and this inhumane practice must stop. Opioid tapering may be necessary for a plethora of reasons, but a slow step-down reduction in dose with concomitant management of symptoms of withdrawal is a good guide and may take months. There is no reason to have another death by suicide, cardiac arrest, or adrenal failure among decent citizens who just happen to have a severe pain problem and need opioids.

 
Last updated on: December 28, 2018
Continue Reading:
Discussing Migraine With Your Patients: A Common Sense Guide for Clinicians

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2 comments.

By stbkazFM on 10/12/2017
It is so refreshing to read your commentary. I have been very concerned about the reactionary response that many providers, groups, insurance companies are taking regarding opioid pain medications. How can we practice medicine and "do no harm", yet tell our chronic pain patients, who are NOT addicted to their medications, that they must stop them... ALL... NOW. I am trying to very slowly wean my chronic pain patients and am communicating with them regularly. They understand the plan, they are engaged in the plan. And when their pain flares up, we are documenting and adjusting their plans. But everyday, I feel that I have to justify myself to pharmacies, insurance plans, pain management providers. I am staying educated about prescribing, indications for use, risks, dependence vs addiction so I can strengthen (and defend) my decisions. Thank you for your editorial and for your patient advocacy.
By bozzuto on 08/31/2017
Not to mention opiate induced hyperalgesia.
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