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I am often asked the question: When is the right time to taper a patient off opioids?
My view is that a patient should be tapered any time the risks exceed the benefits, or when treatment goals are not being met.
Risks of prescribing long-acting medications to patients who may be high risk for opioid addiction are a real concern -- something I've devoted much time and research to.
In the U.S., there appears to be a systemic pattern of adverse selection: giving high-risk opioid regimens (high-dose opioids plus sedatives) to high-risk patients (those with untreated substance abuse and mental health disorders).
Shifting the Focus of Opioid Therapy
We really need to look at whether patients consider their lives improved as a result of opioid treatment. My University of Washington colleague Jane Ballantyne, MD, and I recently published a commentary in theNew England Journal of Medicine in which we argue that the pain scale is not particularly useful when treating chronic pain, as it puts too much emphasis on measuring pain at the expense of functional improvement and quality of life.
The cultural transformation needed in chronic pain treatment is a shift from pain reduction to life improvement.
Pain reduction is always desirable, but may not be possible, and it may not be necessary to achieve a significant improvement in the patient's quality of life.
When patients have not achieved an improvement in overall quality of life on opioid therapy, we need to be able to acknowledge that the treatment hasn't worked and that it's time to taper and try something else.
Negotiating with Patients
The tapering process is guided by patient safety above all. When we taper patients, we're trying to get them to a safer dose. That doesn't always have to be zero. Lower doses have a well-documented decreased risk of overdose and death compared with higher doses.
Tapering does require negotiation with patients. It can be easier to open a dialogue with a patient when treatment is goal-based. If goals aren't being met, the provider can begin to discuss the possibility of a taper.
This is why I recommend that when providers initiate any opioid therapy, they negotiate an agreement with patients about treatment goals, including what would constitute success or failure. Doing this work ahead of time can improve the likelihood of agreement between patient and provider when negotiating a taper.
Patients are often ambivalent about opioid therapy, wishing they could get off opioids but fearful of escalating pain levels. Reassurance that pain levels may rise temporarily, but rarely significantly, can help facilitate a taper.
Proposing a taper to patients we inherit from other providers can be tricky, because we may not have negotiated treatment goals in advance. Patients may already be on high doses or have used long-term opioid therapy and may be reluctant to taper.
Many simply cannot imagine life without their medications, and are fearful that pain will return to unbearable levels if they stop taking them. It's especially important to acknowledge and discuss the fears of these patients.
Supporting the Patient
Fear of opioid withdrawal is also common, and what I try to do with my patients is to acknowledge that tapering off of opioids can be difficult, but that tapering is safe and may help them to become more functional again. We need to pledge to our patients that we will mitigate withdrawal symptoms such as nausea, insomnia, and anxiety to the best of our ability.
Many patients struggle with insomnia and anxiety as they taper opioids. It's important that prescribers don't add medications such as sedatives, benzodiazepines, or muscle relaxants that can increase risk of opioid overdose in unpredictable ways. Tricyclic antidepressants, like nortriptyline, can provide a safer alternative treatment for anxiety and insomnia.
I have found that many patients in the subgroup taking high doses of opioids have untreated or undertreated psychiatric disorders, such as depression or post-traumatic stress disorder, which need to be monitored carefully. Opioids can mask symptoms of these disorders, so that when a patient comes off opioids these symptoms may reappear or worsen.
It's also very important to not simply drop, discharge, or abandon patients who are being tapered: Don't fire your patient!
There is a real risk that they may start visiting multiple providers or emergency rooms to obtain opioids. Or they may go on the street to get heroin, which is a cheap and available opioid.
We need to ensure that we aren't helping to fuel the opioid epidemic, but rather supporting patients to get off of prescription opioids while leading them to safe and effective alternatives.
Reducing the Need to Taper
As providers, we have an important part to play in avoiding overprescribing and ensuring safe tapering. We can begin by prescribing lower initial doses, discontinuing opioids when they are not working, and funding and supporting integrated behavioral health and other non-opioid treatments for chronic pain.
A wide variety of evidence-based treatments has been shown to be effective for chronic pain -- they improve function and quality of life. These treatments range from relaxation training to integrative medicine and behavioral therapy. Access to these approaches needs to be expanded.
All opioid prescribers need to be competent at monitoring risks and tapering opioids, because an unfortunate but common part of opioid therapy is that it doesn't always work and it can become dangerous for patients.
Providers need to be better trained in how to educate patients about the risks and the benefits of opioids. This is one reason we've made our University of Washington training program COPE for Chronic Pain available online so that anyone can access it and become better educated about opioid prescribing.
Mark Sullivan, MD, PhD, is the author of this piece, and a professor of psychiatry at the University of Washington in Seattle. He has over 25 years of experience treating chronic pain in both specialty and primary care settings, and has directed multiple studies funded by NIH and NIDA on the use and effects of prescription opioids.
This article is brought to RheumNow by our friends at MedPage Today. It was originally published on December 16, 2015.