August 25, 2020, 04:12 pm Michael Devitt -- For more than a year, family physician Robert "Chuck" Rich Jr., M.D., of Bladenboro, N.C., has spearheaded a work group in writing a discussion paper on opioid tapering for publication by the National Academy of Medicine.
On August 10, the NAM published the group's paper, "Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings."
The paper is designed to provide FPs and other clinicians with research-based guidance and evidence-based strategies on how and when to initiate opioid tapering protocols in select groups of patients, as well as areas where additional research is needed. Specifically, the paper focuses on patients who are taking opioids for chronic non-cancer pain, are being treated in the outpatient setting, and do not have an opioid use disorder or other substance use disorder.
"It is my hope that this paper provides the additional resources that family physicians will use to become more comfortable in taking care of the chronic pain patient on long-term opioid therapy," Rich told AAFP News.
The discussion paper draws from and expands on information presented in a July 2019 webinar by the NAM's Action Collaborative on Countering the U.S. Opioid Epidemic, of which the AAFP is a member. The webinar was used as source material for the discussion paper, and Rich, a member of the collaborative's Pain Management Guidelines and Evidence Standards Working Group.
Given the complexity associated with opioid tapering, the authors made two clarifying statements in the paper's introduction.
First, they emphasized that "any medical action taken should involve as much patient buy-in as possible and should not be driven by rigid opioid dose cutoffs and misinterpreted guidelines."
Second, they wrote that they also "support sustaining patients on their existing medication at its existing level if patients are continuing to benefit from use, are not experiencing significant side effects, and express the desire to remain on their current medication as opposed pursuing a taper," adding that in these types of cases, the risks of opioid tapering would outweigh the potential benefits.
The paper focuses on several key steps in the opioid tapering process, including
For each step, the paper discusses best practices based on available evidence, along with current research gaps.
The paper also contains a decision aid to assist clinicians and patients in implementing an opioid taper. The authors stressed, however, that the decision aid should be used only as a guide.
"The needs of each patient are unique and should be approached on a case-by-case basis," the authors wrote. "Clinicians should review the risks and benefits with the patient and decide how to proceed with the tapering process in a way that is appropriately informed by individual circumstances and should minimize symptoms of opioid withdrawal."
While much research has been conducted on opioid tapering, the authors found the evidence lacking for a significant portion of the approaches and considerations discussed in the paper. As a result, they highlighted several areas where additional research needs to be done. Findings in those areas, they believe, will have immediate impacts on the safety and efficacy of opioid tapers and have the biggest effect on the implementation of opioid tapering.
The authors acknowledged that ideally, both patients and clinicians would be supported by a team of individuals to assist them in the tapering process, but that in most cases, having that type of assistance is not possible. To build up the processes discussed in the paper, the authors wrote that health care systems will need to take additional actions, such as incentivizing team-based tapering support, expanding behavioral health services, incentivizing more primary care clinicians to provide tapering services, and supporting increased patient access to adjunctive treatments and medications.
Rich, who has treated many patients who have experienced chronic pain, including patients who were previously cared for by other clinicians, told AAFP News that ideally, opioid tapering would consist of a shared decision-making process between patient and physician.
In many instances, however, FPs should be prepared to encounter a number of challenges, including patient readiness for change, access to patient resources such as behavioral health services, and coverage for adjunctive medications and treatments.
Rich also advised that FPs should be prepared for the tapering process to take considerably longer than originally expected, and that the process could include "repeated starts and stops" depending on factors that could impact the patient's experiences related to pain and function.
Considering all the variables involved with successful opioid tapering, Rich acknowledged that some clinicians may not want to provide that type of care for patients who have chronic pain. He hoped, however, that the paper would serve as a valuable guide and encourage more FPs to offer the service.
"There certainly are many pressures that family physicians face in dealing with the chronic pain patient on opioid therapy, and hopefully with an improved understanding of the processes and goals of opioid tapering, more family physicians will feel confident in their ability to safely and appropriately taper opioid therapy in those patients needing to be tapered after a proper review of risks versus benefits," Rich said.
"Hopefully this paper will provide the confidence and skill for more family physicians to engage these patients in the tapering process and work with them in order to achieve a successful endpoint guided by appropriate pain control and preservation of function," he added.