Tapering Long-term Opioid Therapy in Chronic Pain

Tapering Long-term Opioid Therapy in Chronic Noncancer Pain – June 2015 – 2015 Mayo Foundation for Medical Education and Research.

This is an official document from Mayo Clinic to execute a medically proper opioid taper. While it strongly implies that *all* patients prescribed opioids have OUD and they *all* must stop taking them…

  • Nowhere does it say it’s OK to simply stop prescribing and abandon patients.
  • Nowhere does it say all patients must be tapered to zero.

Abstract

Increasing concern about the risks and limited evidence supporting the therapeutic benefit of long-term opioid therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids.

In addition to overt addiction or diversion, the presence of

  • adverse effects,
  • diminishing analgesia,
  • reduced function and quality of life, or
  • the absence of progress toward functional goals

can justify an attempt at weaning patients from long-term opioid therapy.

However, discontinuing opioid therapy is often hindered by patients’ psychiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers.

I find it bizarre that no mention is made of the patients’ pain, for which they were taking the opioids when pain is almost the only symptom opioids are ever prescribed for

The aim of this article is to review the existing literature and formulate recommendations for practitioners aiming to discontinue long-term opioid therapy.

Specifically, this review aims to answer the following questions:

  1. What is an optimal opioid tapering regimen?
  2. How can the risks involved in a taper be managed?
  3. What are the alternatives to an opioid taper?

A PubMed literature search was conducted using the keywords chronic pain combined with opioid withdrawal, taper, wean and detoxification. Six hundred ninety-five documents were identified and screened; 117 were deemed directly relevant and are included.

On the base of this literature review, this article proposes evidence-based recommendations and expert-based suggestions for clinical practice.


Here’s the rest of this long detailed article:

Indications for Tapering of Long-term Opioid Treatment

Adverse effects often [but not always! -zyp] outweigh the benefits of long-term opioid treatment:

  • sedation,
  • decreased concentration and memory,
  • drowsiness,
  • changes in mood,
  • constipation,
  • dry mouth,
  • abdominal pain,
  • nausea,
  • hormonal changes with consequences such as sexual dysfunction, and
  • osteopenia

may limit treatment tolerability

The benefits of long-term opioid treatment can also be questioned when a patient reports inadequate analgesia despite high doses (tolerance), reduced function, quality of life, or absence of progress toward therapeutic goals.

Table 1 presents the indications for tapering long-term opioid treatment.

 

This can include inappropriate use,

  • failure to comply with monitoring (after excluding this failure is due to personal cost burden),
  • selling prescription drugs,
  • forging prescriptions,
  • stealing or borrowing drugs,
  • aggressive demand for opioids,
  • injecting oral or topical opioids,
  • unsanctioned use of opioids,
  • unsanctioned dose escalation,
  • concurrent use of illicit drugs,
  • obtaining opioids from multiple prescribers and/or multiple pharmacies,
  • recurring emergency department visits for chronic pain management

4.Deterioration in physical, emotional, or social functioning attributed to opioid therapy

5.Resolution or healing of the painful condition

Addiction (ie, SUD or more specifically opioid use disorder [OUD]) is a psychiatric diagnosis that involves use despite negative consequences and/or loss of control over use, compulsions, and cravings

Any patient, when left in enough pain for long enough would show exactly these behaviors to get relief.

That’s why torture is so effective. When a victim is being “passively” tortured (hanging from their hands or feet for hours) no one would argue that it would be any doctor’s duty to free him.

Most people feel morally compelled to intervene if possible when they see someone else suffering. It’s not always practical, smart, or safe, but most of us do want to help.

Yet, if this victim goes on to develop lifelong chronic pain in knees or wrists due to his ordeal, tendons and ligaments that were overstretched and permanently damaged, the doctor is ordered to stand aside and leave them hanging.

Among patients with chronic pain, adherence vs abuse can be seen on a spectrum, and OUD is a difficult diagnosis to establish with certainty, justifying involvement of an addiction specialist for initial evaluation and follow-up.

Although the current review aims to focus on patients with CNCP, patients with cancer pain may develop similar difficulties related to opioid use.

Increased Pain

Many patients fear that their pain will increase during an opioid taper. However, according to studies of long-term opioid treatment tapers, overall, patients report improvements in function without associated worsening in pain (aggregated N=1007) or even decreased pain levels (aggregated N=513)

Who are these people? They don’t sound like the pain patients I have come to know.

I believe these are the folks mentioned by Dr. Michael Schatman, editor in chief of the Journal of Pain Research in the post Pain patients getting new attention from top at FDA .

Experimental pain testing protocols suggest that sensory hyperalgesia may appear immediately after discontinuation of long-term opioid treatment.

Similar hyperalgesia has been described postoperatively, when the use of short-acting opioids is abruptly discontinued at the end of surgery.

In light of the functional improvement and pain reduction typically reported after discontinuation of long-term opioid treatment

hyperalgesia appears to be a brief, time-limited phenomenon.

Dropout

When specifically examining predictors for difficulties during tapering among 29 patients, depressive symptoms at initiation were described as a significant factor not only for drop out (rate, 34%) but also for relapse (rate, 32%)

In a study of 42 patients randomized into 2 groups, half were informed at study initiation of a maintenance treatment option in case of taper failure, whereas the other half did not receive this option. Of the patients without an opioid maintenance option, 76% quit treatment within 3 weeks compared with 5% in the group with an opioid maintenance option

Maintenance dosing is the correct medical response to attempts at tapering since some patients truly need them to control their unbearable pain. For them, pain increases as opioids are withdrawn, a perfectly logical outcome indicating that these medications are necessary and appropriate for those patients.

Arbitrary tapers regardless of medical condition or individual patient response seem like malpractice.

Finally, a review questioning the necessity for pain rehabilitation programs to taper opioids found evidence that mandatory opioid weans could be associated with increased dropout rates especially in patients taking high levels of opioids

Yes, as in any other medical scenario, when a patient’s necessary medication is withdrawn they can be expected to have “poor outcomes” – more accurately described as “disastrous outcomes”.

The desperation arising from unremitting pain leads such patients to abandon the “medical care” that has failed them and turn to other methods of pain relief: becoming bed-bound, using street drugs, or suicide.

In the long term, the goals are to reduce adverse effects and mitigate or address risks of long-term opioid treatment (opioid reliance, chemical coping, and self-medication with risk of overdose), which imply maintaining reduced opioid consumption or abstinence.

low pain at the end of an opioid taper is predictive of long-term abstinence from opioids in CNCP

Function

Increasing or maintaining function is a key long-term goal in treating those with chronic pain. Disability in the context of chronic pain is influenced by many psychosocial factors, including coping strategies and mood.

Medicolegal Implications

Finally, there are significant medicolegal concerns for those prescribing long-term opioid treatment for CNCP. Deaths by unintentional overdose or suicide represent the most serious consequences, leading to potential civil liability or licensing board investigations.

Examination of closed malpractice claims among pain medicine specialists revealed that 3% were related to medication management, with claims arising mostly after patients died of opioid overdose

3% is not much, usually, so little it’s not considered worthy of mention, but here is treated as though it were a significant number.

The predominant reason for inappropriate care was a failure of the prescribing physician to adequately verify a patient’s prior medical history before providing the first opioid prescription, which could have revealed concurrent use of drugs and/or alcohol.

Medication Choice

Buprenorphine-naloxone and methadone are less subject to misuse (although not fully preventing intentional misuse) and are frequently used to taper patients with OUD

These universal mandatory tapers ignorantly assume (without evidence) that all patients prescribed opioids are suffering from OUD.

This is purely the influence of A. Kolodny, who believes all pain medications are “heroin pills” and “cause addiction” if used over more than a few weeks.

Methadone is a long-acting full μ-opioid receptor agonist with strong analgesic potency. Methadone has a long and variable elimination half-life (8 to 59 hours), causing drug accumulation during rapid dose escalation, and can affect the cardiac cycle (QTc prolongation).

It is the only medication approved by the US Food and Drug Administration for detoxification treatment of OUD.

Luckily, methadone is also a potent pain reliever so if pain patients could at least be maintained on this opioid (at a sufficient dose to relieve their pain) they might be able to get by,

Recommendations

Taper Speed

There is no published comparison of speed of tapers in patients with long-term opioid treatment for CNCP, although such research would be of great interest. There is no strong evidence from the SUD literature toward rapid or ultrarapid tapers compared with slower ones, and the usefulness of faster tapers for patients receiving long-term opioid treatment in the community has been questioned

Not only is there “no strong evidence”, there’s been no research whatsoever on the inappropriate tapering of opioids used for pain.

In the absence of validated protocols, empirical plans have been proposed (recommendation GRADE D)

As with most of the rules and procedures suggested by the CDC guidelines, they are all based on flimsy evidence (Grade D).

Plans often first reduce the dose of the medication to the smallest commonly available unit dosage and then increase the amount of time between doses (eg, in a regimen of 60 mg of extended-release morphine every 8 hours, first decreasing to 15 mg of extended-release morphine every 8 hours, then increasing the interval between the doses).

The Department of Veterans Affairs and the Department of Defense have developed a fact sheet that suggests either a taper by 20% to 50% of the original dose per week for patients who are not presenting with SUD or faster protocols with daily decreases by 20% to 50% of the initial dose down to a threshold (30-45 mg of morphine every day), followed by decreases every 2 to 5 days.

According to our center’s experience (recommendation GRADE D), a decrease of 10% of the original dose every 5 to 7 days until 30% of the original dose is reached, followed by a weekly decrease by 10% of the remaining dose, rarely precipitates withdrawal symptoms and facilitates adherence.

Again, based on poor grade D evidence, meaning without verification by scientifically sound research.

The speed of the taper should be inversely correlated with duration of treatment to prevent withdrawal symptoms (eg, bimonthly to monthly dose adjustments can be considered in case of long-term opioid treatment exceeding 2 years)

Medication Choice

The rationale for switching a patient treated with long-term opioid treatment for CNCP to taper with buprenorphine or methadone is not entirely clear, and there is no evidence to support such practice (recommendation GRADE D).

There’s no evidence to support any of their “suggestions”, not even in the CDC Guideline that started all this.

A recent systematic review of the body of literature studying CBT and interdisciplinary programs for patients with CNCP tapering from long-term opioid treatment pointed out its limitations

Therefore, the authors of the review renounced drawing conclusions regarding the effectiveness of psychological, alternative, or interdisciplinary interventions to support patients tapering from opioids

Long-term outcomes from multidisciplinary programs are rarely described.

But even without long-term studies, they are recommended by every anti-opioid believer, even the CDC, while the lack of long-term studies on opioids for pain management is considered evidence that “opioids don’t work”.

Well, then neither do multidisciplinary programs or any of the other “alternative” treatments of pain, none of which have been studied longer than 3 months.

1.Provide detailed case documentation, including diagnosis, physical examination, substance abuse risk assessment, review of prior records, review of prescription monitoring data, and all of the efforts below.

2.Narrowly define the treatment as tapering or weaning; avoid the term detoxification unless in a licensed addiction setting.

3.In case of doubt regarding a substance use disorder, obtain a formal opinion from an addiction specialist before stating a tapering program.

4.Collaborate legitimately with relevant medical or mental health specialists, including referrals for addiction and psychiatric care. Consider making prescriptions conditional to attendance at specialized consultations.

5.Make every effort to rule out criminal activity if this suspicion is present. In case of known diversion, the physician should not prescribe even at lower or decreasing doses.

6.Involve a psychiatrist or legal counsel in case of threats of suicide or of “buying drugs off the street”.

7.Reassure patients that their heath is being taken seriously, that pain will be treated, and that they will not be abandoned. Offer nonopioid treatments

8.Use proper patient informed consent and opioid taper agreement (Table 5Table 5)

.9.If discharge occurs, communicate with the patient about the cause and the end of treatment.

A review underlines the absence of consensus to support buprenorphine as an effective treatment in opioid-naive patients with CNCP, and this might be explained by the weak analgesic effects of buprenorphine and its ceiling effects.

That’s right: buprenorphine only works for low pain levels, even though it’s touted as a cure-all for both pain and addiction. (especially by A. Kolodny – see An Open Letter to Dr. Andrew Kolodny )

Methadone as a specific opioid for long-term opioid treatment in patients with CNCP is supported by limited evidence.

…patients with CNCP (N=60) with OUD were followed up (mean of 34 months, 68% retention rate) after a switch to methadone (mean dose, 99.5 mg/d), reporting satisfying pain control and physical function in all 42 patients who were still in the program

Finally, a randomized clinical trial in patients with OUD and chronic pain (N=54) comparing methadone with buprenorphine-naloxone did not find a significant difference in pain reduction or dropouts; however, fewer in the methadone group used nonprescribed opioids

…because those that were only given buprenorphine didn’t get sufficient pain relief.

Recommendations

Maintenance with a long-acting opioid (eg, extended-release morphine or transdermal fentanyl) is an option, although there is no evidence to date favoring in general such a regimen over a short-acting one.

In other words, patients with CNCP should just be maintained on the opioids that currently work for them.

Opioid maintenance for treating CNCP requires close monitoring, support, and reassessment over time, as underlined by expert panels and regulatory instances

This is what we’ve been doing all along, so just leave us alone.

Conclusion

There is mounting concern regarding the use of long-term opioid therapy for patients with CNCP, and increasing numbers of physicians are contemplating tapering for their patients.

Although some evidence can be translated from the field of SUD to inform care in patients with CNCP, little specific and high-quality research has focused on guiding tapering from long-term opioid treatment and on specific support needed to manage risks and issues in this process.

In the meantime, drawing on the available literature and our own clinical experience, we have put forth some suggestions to help guide physicians. Although some of these recommendations may be challenged by future evidence, we hope most will be validated and strengthened by further research. Overall, we suggest aiming to find the best possible equilibrium for each patient, balancing the risks and benefits of opioids in a way that optimizes function, and establishing realistic opioid taper or maintenance goals accordingly.

The suggestion to find the “best possible equilibrium for each patient” precisely contradicts implementing universal tapers and doses.

They cannot claim they are providing individualized patient care if they are applying the same treatment (taper) standards (below 90MME or even 50MME) to all patients prescribed a particular medication, regardless of their medical condition.

Guidance on opioid tapering for chronic pain

 

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