ASRA Pain Medicine Update

Opioid tapers are a hot topic these days. Physicians of all stripes inevitably encounter patients chronically using opioids in a variety of clinical settings. In 2015 alone, 4.3 million Americans self-administered opioids for chronic non-cancer pain.¹ Patients routinely use opioid analgesics following ambulatory surgical procedures. Many continue to use opioid therapy in the long-term, and some develop opioid use disorder (OUD).² Opioid prescription rates and average morphine equivalent dosing (MED) have declined from 2012 highs after the release of the 2016 Centers for Disease Control and Prevention (CDC) guidelines. However, overdose deaths, primarily due to heroin and illicit fentanyl, continue to rise.³

Opioids do not improve pain or function compared with non-opioid analgesics.⁴ They worsen clinical depression, dysregulate sex hormones, increase the risk of cardiovascular events, and depress respiration in a dose-dependent fashion.⁵ Patients treated with high-dose opioid analgesic regimens (MED > 90) are almost 10 times more likely to suffer a potentially fatal overdose event compared with non-opioid users and 100 times more likely to develop an OUD.⁵ Opioid misuse rates approach 50%-75% in some cohorts.⁵

Practitioners may be reluctant to prescribe or continue chronic opioid therapy because they fear Drug Enforcement Administration and regulatory board sanctions.¹ Additionally, patients suffering from chronic pain can be difficult to manage, and office encounters can be both time-consuming and emotionally exhausting.¹ The 2016 CDC guidelines accelerated a flight from prescribing and sparked intense interest in opioid tapering.⁶ In some cases, practitioners misinterpreted the guidelines and patients suffered from rapid, involuntary tapers without adequate support.⁷

Opioid tapering is labor-intensive, and there are no widely agreed upon guidelines about how to accomplish this feat, what dose to achieve, or even which patients should be tapered. The CDC and state medical boards have emphasized that there is no mandatory MED threshold to which patients must be tapered.¹ Stable patients with improved function on “low-dose” regimens (MED < 90) without misuse can safely be maintained on their regimens.⁷Practitioners should consider tapering any patient with poor function, adverse side effects, or medical comorbidities such as pulmonary or cardiovascular disease and sleep apnea.⁷ Patients on high-dose opioid regimens - especially concomitant benzodiazepines - are at highest risk for morbidity and should be given taper priority in the clinical setting.

Many patients initially resist an opioid therapy taper because they fear withdrawal and worsening pain. Yet most studies show that the vast majority of patients on lower-opioid doses (97% in one large study) have less pain, better function, and improved quality of life.⁸ Dr. Anna Lembke’s B.R.A.V.O. method stresses empathy for patients who fear dose reduction by slowing velocity tapers to increase compliance and early treatment of OUD.⁹Multidisciplinary therapy such as interventional pain techniques, psychological counseling, and frequent prescriber visits increase taper success.¹⁰ The Stanford Medicine's continuing medical education course How to Taper Patients Off of Chronic Opioid Therapy is an excellent tapering resource.

Experts classify opioid tapers by duration. Ultra-rapid tapers take seven days or fewer and should be done in a monitored, hospital setting or a detox facility if indicated for addiction. Rapid tapers take 3-4 weeks, and slow tapers can take months. If possible, patients generally benefit from slow, supported tapers. Abrupt tapers, especially from high doses, may precipitate severe withdrawal symptoms and/or lead to psychological decompensation and illicit opioid use.⁵

Taper length should generally be proportional to the duration of chronic opioid therapy.¹ The CDC and Department of Health and Human Services recommend a 10% monthly dose reduction.⁵ Prescribers can slow the taper rate even more if needed and “pause” tapers if the patient struggles. However, efforts should be made to not go back and increase to previous opioid doses once a taper begins. Patients who take short-acting opioids generally taper more quickly than those on long-acting formulations.¹ Patients on both long- and short-acting opioids can taper either first.¹ In my practice, I usually recommend tapering extended-release/long-acting medications initially because of their higher overdose risk. Pharmaceutical availability dictates that almost all tapers end with short-acting formulations in any case.¹ 

Prescribers must treat withdrawal early and aggressively to increase the likelihood of a successful taper. Patients on long-term opioid therapy should be reassured that withdrawal is transient and does not signify worsening of their condition.¹ Withdrawal usually begins after 2-3 drug half-lives and lasts 7-14 days but is not life-threatening in the absence of rare comorbidities. Patients commonly experience anxiety, nausea, cramps, shivering, and lacrimation and may be tachycardic or hypertensive. Withdrawal happens even with slow tapers, but high-dose patients tapered too rapidly may have severe and disabling reactions. Norepinephrine hyperreactivity plays a prominent role and, for this reason, alpha-2 adrenergic agonists like clonidine and lofexidine may be helpful.¹ Clonidine can be dosed 0.1-0.2 mg four times daily with a maximum dose of 1.2 mg over 24 hours. Nausea can be treated with ondansetron and diarrhea with loperamide or dicyclomine. Prescribers should not use benzodiazepines routinely during opioid tapers because they increase sedation and respiratory depression and produce cross-dependence. Patients with mood disorders, anxiety, or dysphoria benefit from anti-depressants and counseling access.¹

Opioid tapers do not always go according to plan. Some patients may misuse opioids or be diagnosed with OUD during a taper. Prescribers should be vigilant for addictive behavior like dysphoria and craving and monitor urine toxicology. Buprenorphine is a safe and effective treatment for OUD, and most patients stabilize on 16 mg daily.¹ Patients with so called “chronic/complex persistent dependence” (CPD) do not meet Diagnostic and Statistical Manual of Mental Disorders¹³ criteria for OUD and fail tapering. However, elective rotation to buprenorphine usually manages their pain and improves dysphoria, depression, and quality of life.¹¹ Most states allow off-label prescribing of sublingual buprenorphine for chronic pain and opioid dependence. Suboxone (buprenorphine + naloxone) should be reserved for patients with OUD. Suboxone prescribers must apply for a special Drug Addiction Treatment Act 2000 or “X-Waiver,” which can be obtained after eight hours of online coursework. Those interested in obtaining a waiver should seek further information online at the Substance Abuse and Mental Health Services website (www.SAMHSA.gov).

Patients with personality disorders, substance abuse, ethanol and tobacco abuse, or depression and post-traumatic stress disorder may resist tapering and are less likely to be successful.¹ These patients should be tapered gradually, and prescribers should enlist mental and allied health assistance. Conversely, patients without mental health issues on low-to-moderate dose opioids usually can taper successfully. Prescribers may want to enlist the support of concerned family members who often notice deterioration in their loved ones’ function as well as patterns of misuse. Patients scheduled for elective surgery should consider tapering preoperatively because chronic opioid therapy worsens efforts at perioperative pain management, complicates recovery, and increases surgical-site infections and 90-day readmission rates.¹² Well-conceived perioperative pain management clinics have established elective surgical opioid taper protocols and have achieved successful improvements in perioperative outcome variables.

Opioid overdose deaths will probably increase in the coming years despite ubiquitous regulatory oversight and immense resources devoted to combatting the opioid epidemic. As anesthesiologists, we have an obligation to deal responsibly and empathically with the opioid question whether we are in the operating room, perioperative clinic, or office. In select patients, careful opioid dose reduction is a worthy endeavor which usually improves pain and function while improving safety for our patients and communities.

Andrew Chapman, MD, is an assistant professor of anesthesiology and the director of the Chronic and Inpatient Pain Division at VCU Health in Richmond, VA.

References

1. Davis MP, Digwood G, Mehta Z, McPherson ML. Tapering opioids: a comprehensive qualitative review. Ann Palliat Med. 2020;9(2):586-610.
2. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in U.S. adults. JAMA Surg. 2017;152(6).
3. Bohnert ASB, Guy GP, Losby J. Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention’s 2016 Opioid Guideline. Ann Intern Med. 2018;169:367-75.
4. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA. 2018;319(9):872-82.
5. Lembke A, Humphreys K, Newmark J. Weighing the risks and benefits of chronic opioid therapy. Am Fam Physician. 2016;93(12):982-90.
6. Fenton JJ, Agnoli AL, Xing G et al. Trends and rapidity of dose tapering among patients prescribed long-term opioid therapy, 2008-2017. JAMA Netw Open. 2019;2(11):e1916271.
7. Dowell D, Haegerich T, Chou R. No shortcuts to safer opioid prescribing. N Engl J Med. 2019;380(24):2285-7.
8. Fishbain DA, Pulikal A. Does opioid tapering in chronic pain patients result in improved pain or same pain vs increased pain at taper completion? A structured evidence-based systematic review. Pain Med. 2019;20(11):2179-97.
9. Stanford Medicine. How to Taper Patients off of Chronic Opioid Therapy. CME Course. Available at: https://online.stanford.edu/courses/som-ycme0022-how-taper-patients-chronic-opioid-therapy. Accessed March 20, 2020.
10. Sullivan MD, Turner JA, DiLodovico C et al. Prescription opioid taper support for outpatients with chronic pain: a randomized controlled trial. J Pain. 2017;18(3):308-18. 
11. Daitch D, Daitch J, Novinson D et al. Conversion from high-dose full-opioid agonists to sublingual buprenorphine reduces pain scores and improves quality of life for chronic pain patients. Pain Med. 2014;15(12):2087-94.\
12. Jain N, Phillips FM, Weaver T et al. Preoperative chronic opioid therapy: a risk factor for complications, readmission, continued opioid use and increased costs after one- and two-level posterior lumbar fusion. Spine. 2018;43(19):1331-8.
13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). 2013. Washington, DC.