The National Academy of Medicine's Action Collaborative on Countering the U.S. Opioid Epidemic,(nam.edu) of which the AAFP is a member, will host a free webinar from 3 to 4:30 p.m. EDT on July 22(nam.edu) to discuss best practices and evidence standards on opioid tapering.
Five panelists will present a number of patient case scenarios and discuss pain management challenges from patient and caregiver perspectives to inform current guidance on opioid tapering, how it is applied in practice and the strength of the evidence behind it.
Family physician Robert "Chuck" Rich, M.D., of Bladenboro, N.C., helped develop topics for the webinar. He told AAFP News he also heads a work group that's writing a discussion paper on tapering opioids that NAM plans to publish by early 2020.
The forthcoming paper, Rich said, will incorporate what's covered during the webinar and go beyond that to offer a survey of the topic, looking primarily at patients who have been on long-term opioids for the management of chronic pain, often in conjunction with other medications such as benzodiazepines and hypnotics.
- The National Academy of Medicine's Action Collaborative on Countering the U.S. Opioid Epidemic will host a free webinar from 3 to 4:30 p.m. EDT on July 22 to discuss best practices and evidence standards on opioid tapering.
- Five panelists will present patient case scenarios and discuss pain management challenges from patient and caregiver perspectives to inform current guidance on opioid tapering, how it is applied in practice and the strength of the evidence behind it.
- Family physician Robert "Chuck" Rich, M.D., of Bladenboro, N.C., helped develop topics for the webinar and heads a work group that's writing a paper on tapering opioids that NAM plans to publish by early 2020.
"The NAM goal for this paper is to highlight the issue and review some of the current strategies for dealing with the topic and its impact on practice, particularly primary care," he said.
The paper will look at the available strategies for tapering these medications as appropriate, pharmacologic and nonpharmacologic aids to facilitate those strategies, and the evidence basis for those strategies and aids to treatment, Rich said.
"The paper will also look at other patient populations where a need for opioid tapering may be indicated, including the recent postsurgical patient, as well as the recent post-trauma patient on opioids and the aforementioned polypharmacy patient," he added.
When considering tapering a patient on long-term opioid therapy for chronic pain, Rich said he starts by evaluating why the patient is on opioids and whether there is functional benefit from use of these medications.
He said he also tries to determine whether the patient has any underlying behavioral or substance abuse issues that may increase the risk of misuse, overdose or death.
"Once I have reviewed those considerations, I then lay out a plan for tapering the opioid therapy -- along with other high-risk medications -- to the patient, my reasons for doing so, and my goals for tapering and subsequent reduction and/or discontinuation of those medications," Rich said.
This is done via a shared decision-making process with the patient, he added, and if appropriate, may involve the joint efforts of other clinicians such as behavioral health or substance abuse specialists.
"Additionally, to facilitate such a taper, I try to maximize my use of adjunctive treatments to lessen the need for opioids, and once I have those therapies ongoing, I then set a start date with the patient, as well as agreeing upon an amount to taper and how often," Rich said.
Rich uses functional assessment tools to monitor for significant deterioration in patients' functional status, and if there is a problem, pauses or stops the tapering process. He will then revisit the subject of tapering later on but will avoid escalating the opioid dosage in the interim.
"While there is little evidence-based research to guide family physicians about the recommended rate of opioid tapering, I typically aim for a 10% or greater reduction monthly on an individualized basis with each patient," he said.
Barriers to Tapering
The most common problem with tapering opioids, Rich said, is precipitating withdrawal activity and possibly worsening a patient's functional status.
"I try to develop a plan with the patient to recognize the signs of withdrawal and then treat those symptoms if they occur," he said. "The worst outcome of withdrawal is for the patient to turn to the use of street drugs or illegally obtained prescription opioids to deal with the symptoms."
Although uncomfortable, Rich said withdrawal is typically not life-threatening and the rate of further tapering can be adjusted to minimize those symptoms. With proper assessment, planning and patient buy-in, tapering and/or discontinuing opioid use can be successful while minimizing patient side effects.
"The most common challenge we all face in this patient population is the patient resistant to any attempt at tapering," he said. "I have occasionally had a new chronic pain patient come to me from other providers requesting assistance in tapering, but this is the exception."
Most patients require multiple discussions about tapering before agreeing to do so, even in the face of high opioid dosing or polypharmacy with other high-risk medications, Rich said.
Lack of availability of adjunctive treatments to aid in the tapering process can be a challenge for some patient populations, he noted, but the AAFP, along with other specialty organizations, continues to actively advocate for improved coverage of alternative therapies.
Although patients may describe concerns about worsened pain or other symptoms during the tapering period, with patience and proper encouragement, patients can complete the process, Rich said.
"I have had patients thank me afterwards for my persistence about tapering and expressed relief that they were not needing to take as many opioids and high-risk medications as they were previously," he said.
"I encourage our members to join the webinar and hear the discussions about the common patient scenarios that many family physicians encounter in practice when considering tapering," Rich said. "The coming discussion paper will build on the information presented during the webinar and add additional strategies that our members should find useful for tapering."
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