Curbside Consultation

Tapering Long-Term Opioid Therapy

 

Am Fam Physician. 2020 Jan 1;101(1):49-52.

Case Scenario

My patient is a 54-year-old construction worker who has been taking prescribed opioids for more than a decade for chronic knee and back pain. During the past year, he has admitted that he feels “stuck on these drugs.” His pain is not well controlled, and his wife has complained that he seems “out of it.” We have talked about reducing his prescription or stopping opioids, but he is reluctant and worried. How can I help my patient taper his regimen to minimize withdrawal and maximize his chances for success?

Commentary

Decreasing or discontinuing long-term opioid therapy (opioids taken daily for 30 days or longer) is clinically challenging, especially in patients on high dosages (e.g., morphine equivalent is greater than 90 mg per day).

The BRAVO (broaching the subject, risk–benefit calculation, addiction, velocity and validation, other strategies) protocol, based on expert consensus and emerging evidence, provides a safe and compassionate framework for opioid tapering.1,2

BROACHING THE SUBJECT

Suggesting an opioid taper can trigger extreme anxiety in patients. The physician should acknowledge this feeling, normalize it, and express empathy for the patient’s distress.

Begin by telling the patient, “I’ve been thinking a lot about your chronic pain.” This communicates that the benefit of an opioid taper has been carefully considered and that the plan for a taper is not impulsive or retaliatory. It is rather the result of careful deliberation, including medical assessment of risk vs. benefit.

Arrange extra time to discuss this delicate topic. Anticipate the patient’s strong emotional reaction. Pledge your support through this difficult process. Facilitating a good therapeutic alliance increases the chances of a successful taper.

RISK–BENEFIT CALCULATION

The risk–benefit calculation helps determine whether the relative benefits of opioid therapy outweigh the risks and whether a dose decrease or full taper is indicated.3 This calculation is not about any specific dose of opioids but about weighing the risks and benefits in a given patient and tapering to a place where benefits exceed risks, including the risks of a taper.

An opioid taper should be considered when any of the following situations occur:

  • Failure to provide significant analgesia despite incremental dose increases,

  • Lack of functional improvement over time,

  • Prescription of high dosages of opioids (morphine equivalent is greater than 90 mg per day),

  • Significant physical risk factors are present (e.g., sleep apnea, prolonged QT interval, pulmonary disease),

  • Adverse effects of medication interfere with quality of life,

  • Dangerous coprescribing (e.g., benzodiazepines, muscle relaxants, other sedatives),

  • Patient request.

ADDICTION HAPPENS

Think of the four Cs (control, compulsion, craving, continued use despite consequences) to remember the 11 diagnostic criteria for substance use disorders from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5).4 Control refers to out-of-control use (e.g., using more than intended); compulsion refers to mental preoccupation with using and using against a conscious desire to abstain; craving refers to physiologic and/or mental states of wanting; and continued misuse despite consequences refers to persistent misuse despite social, legal, economic, interpersonal, and other problems that arise as a result of use.

It is important to distinguish between dependence and addiction. Someone who takes a prescribed daily opioid pill for pain may be dependent on opioids (i.e., needs more and more medication to get the same effect [tolerance]) and may experience opioid withdrawal when cutting back or discontinuing use; however, the person is not addicted to opioids by virtue of taking them as prescribed. This individual would meet criteria for a diagnosis of opioid dependence, physiologic, but not a diagnosis of opioid use disorder.

It is possible to have an opioid use disorder without being dependent. Someone who binges on opioids to the point of respiratory suppression or risking death, but does not take opioids daily, will not develop the tolerance and withdrawal symptoms (i.e., physical dependence) that arise with daily use. This individual would meet criteria for a diagnosis of opioid use disorder; however, they would not have a diagnosis of opioid dependence, physiologic.

Patients who become addicted to prescription opioids may take more of the medication than directed; hoard the medication and take a single large dose to achieve an altered mental status; take the medication to improve mood and energy rather than to treat pain; spend a lot of time and effort trying to get more medication; crave the medication; or get into personal, occupational, or medical difficulties because of use of the medication.

Patients who develop an opioid use disorder should be referred for treatment. Of the available opioid use disorder treatments, robust evidence supports opioid agonist therapy in the form

Author disclosure: No relevant financial affiliations.

Address correspondence to Anna Lembke, MD, at alembke@stanford.edu. Reprints are not available from the author.

References

show all references

1. U.S. Department of Health of Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. October 2019. Accessed November 20, 2019. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf...

2. Oregon Pain Guidance. Tapering—guidance and tools. Clinical update December 2018. Accessed November 20, 2019. https://www.oregonpainguidance.org/guideline/tapering/

3. Lembke A, Humphreys K, Newmark J. Weighing the risks and benefits of chronic opioid therapy. Am Fam Physician. 2016;93(12):982–990. Accessed October 30, 2019. https://www.aafp.org/afp/2016/0615/p982.html

4. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2014.

5. Strang J, Babor T, Caulkins J, et al. Drug policy and the public good: evidence for effective interventions. Lancet. 2012;379(9810):71–83.

6. Zoorob R, Kowalchuk A, de Grubb MM. Buprenorphine therapy for opioid use disorder. Am Fam Physician. 2018;97(5):313–320. Accessed October 30, 2019. https://www.aafp.org/afp/2018/0301/p313.html

7. Coffa D, Snyder H. Opioid use disorder: medical treatment options. Am Fam Physician. 2019;100(7):416–425. Accessed October 30, 2019. https://www.aafp.org/afp/2019/1001/p416.html

8. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–1645.

9. Darnall BD, Ziadni MS, Stieg RL, et al. Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Intern Med. 2018;178(5):707–708.

10. Lembke A, Papac J, Humphreys K. Our other prescription drug problem. N Engl J Med. 2018;378(8):693–695.

11. White JM. Pleasure into pain: The consequences of long-term opioid use. Addict Behav. 2004;29(7):1311–1324.

12. 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):308–318.

13. Frank JW, Lovejoy TI, Becker WC, et al. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Ann Intern Med. 2017;167(3):181–191.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

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