HHS Guidance for Dosage Reduction

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Opioid Analgesics – Oct 2019

I’m furious that throughout this detailed 8-page document, the assumption is always that tapers must happen, one way or another. I couldn’t find a single sentence suggesting it may be best to leave patients on some dose of opioids for their pain because, for most of us, opioids are the ONLY effective means of pain control.

More judicious opioid analgesic prescribing can benefit individual patients as well as public health when opioid analgesic use is limited to situations where benefits of opioids are likely to outweigh risks.

Yet they never again mention this case of the benefit being greater than risks, even though that’s the case for so many of us.

At the same time opioid analgesic prescribing changes, such as dose escalation, dose reduction or discontinuation of long- term opioid analgesics, have potential to harm or put patients at risk if not made in a thoughtful, deliberative, collaborative, and measured manner. 

Risks of Rapid Opioid Taper

Opioids should not be tapered rapidly or discontinued suddenly due to the risks of significant opioid withdrawal.

But it doesn’t say anything about NOT tapering or NOT discontinuing.

I worry that this won’t help our situation much at all because it only describes HOW to taper, not WHETHER to taper at all.

Risks of rapid tapering or sudden discontinuation of opioids in physically dependentii patients include

  • acute withdrawal symptoms,
  • exacerbation of pain,
  • serious psychological distress, and
  • thoughts of suicide.

To this, I would add “completed suicide” because that’s what has been happening since these involuntary tapers began after about 2010.

Patients may seek other sources of opioids, potentially including illicit opioids, as a way to treat their pain or withdrawal symptoms.

Whether or not opioids are tapered, safe and effective nonopioid treatments should be integrated into patients’ pain management plans based on an individualized assessment of benefits and risks considering the patient’s diagnosis, circumstances, and unique situation.

Clinicians have a responsibility to provide or arrange for coordinated management of patients’ pain and opioid-related problems, and they should never abandon patients.

Consider tapering to a reduced opioid dosage, or tapering and discontinuing opioid therapy, when:

  1. pain improves
    [but that’s the very reason we take opioids in the first place!]
  2. the patient receives treatment expected to improve pain
    [expected, but not proven, effective for this patient?]
  3. the patient requests dosage reduction or discontinuation
  4. pain and function are not meaningfully improved
    [between this and the first criteria, “pain improves”, they’ve covered all possible pain situations,
    making tapering mandatory for all pain patients]
  5. the patient is receiving higher opioid doses without evidence of benefit from the higher dose
  6. the patient has current evidence of opioid misuse
  7. the patient experiences side effects that diminish quality of life or impair function
  8. the patient experiences an overdose or other serious event (e.g., hospitalization, injury),  or has warning signs for an impending event such as confusion, sedation, or slurred speech
  9. the patient is receiving medications (e.g., benzodiazepines) or has medical conditions (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) that increase risk for adverse outcomes.
    [if two medications should not be taken together, they insist the opioid must stop when it would be just as effective to “taper” the other drug]
  10. the patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear.

First, they tell us that we shouldn’t expect full pain relief down to level zero. Then they tell us that if “pain and function are not meaningfully improved”, this is an indication that opioids should be tapered.

So, our opioids should be tapered under these two conditions:

  1. If our pain IS “meaningfully improved” while taking opioids
  2. if our pain IS NOT “meaningfully improved” while taking opioids

That covers all situations, so it sounds like the taper is required in every case.

Important Considerations Prior to Deciding to Taper

The duration of increased pain related to hyperalgesia or opioid withdrawal is unpredictable and may be prolonged in some patients

…especially when facing the pain that opioids has been suppressing 

Avoid insisting on opioid tapering or discontinuation when opioid use may be warranted (e.g., treatment of cancer pain, pain at the end of life, or other circumstances in which benefits outweigh risks of opioid therapy). The cdc guideline for prescribing opioids for chronic pain does not recommend opioid discontinuation when benefits of opioids outweigh risks.

Avoid misinterpreting cautionary dosage thresholds as mandates for dose reduction. While, for example, the cdc guideline recommends avoiding or carefully justifying increasing dosages above 90mme/day, it does not recommend abruptly reducing opioids from higher dosages. Consider individual patient situations.

Some patients using both benzodiazepines and opioids may require tapering one or both medications to reduce risk for respiratory depression. Tapering decisions and plans need to be coordinated with prescribers of both medications. If benzodiazepines are tapered, they should be tapered graduallyv due to risks of benzodiazepine withdrawal (anxiety, hallucinations, seizures, delirium tremens, and, in rare cases, death).

Avoid dismissing patients from care.

Just avoid it? How about saying “don’t do it”?

This practice puts patients at high risk and misses opportunities to provide life-saving interventions, such as medication-assisted treatment for opioid use disorder. Ensure that patients continue to receive coordinated care.

What about the life-saving intervention of pain control?

Patients who were forced to taper now have to face their uncontrolled pain every day and, for some, this makes living unbearable so they kill themselves.

In such cases, effective pain control is all that allows them to survive.

There are serious risks to noncollaborative tapering in physically dependent patients, including acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, and patients seeking opioids from high-risk sources.

Important Steps Prior to Initiating a Taper

commit to working with your patient to improve function and decrease pain.

In many cases, including mine, this is accomplished using opioids. Without them, my function decreases becasue my pain increases.

In this whole document, this simple logic is ignored, making me wonder about the sanity and intelligence of those who are dictating our treatment.

Use accessible, affordable nonpharmacologic and nonopioid pharmacologic treatments. Integrating behavioral and nonopioid pain therapies before and during a taper can help manage pain and strengthen the therapeutic relationship. 

Depression, anxiety, and post-traumatic stress disorder (ptsd) can be common in patients with painful conditions, especially in patients receiving long-term opioid therapy.

Depressive symptoms predict taper dropout.

How does a patient “drop out” of a taper?  Their only options are to taper with a doctor supervising the disaster or without a doctor. Either way, they will receive no more opioid pain relief.

There’s no possibility of “dropping out” of a taper and getting your full dose back, so this whole idea makes no sense unless tapers are voluntary, which they seem not to be.

Treating comorbid mental disorders can improve the likelihood of opioid tapering success. 

If your patient

  • has serious mental illness,
  • is at high suicide risk, or
  • has suicidal ideation,

offer or arrange for consultation with a behavioral health provider before initiating a taper.

This still assumes tapering is necessary for all chronic pain patients under all circumstances.

If a patient exhibits opioid misuse behavior or other signs of opioid use disorder, assess for opioid use disorder using dsm-5  criteria. If criteria for opioid use disorder are met (especially if moderate or severe), offer or arrange for medication-assistedvi treatment.

Share Decision Making with Patients

Discuss with patients their perceptions of risks, benefits, and adverse effects of continued opioid therapy, and include patient concerns in taper planning. For patients at higher risk of overdose based on opioid dosages, review benefits and risks of continued high-dose opioid therapy.

If the current opioid regimen does not put the patient at imminent risk, tapering does not need to occur immediately. Take time to obtain patient buy-in.

This still assumes that tapering is going to happen eventually.

For patients who agree to reduce opioid dosages, collaborate with the patient on a tapering plan.

If a patient agrees to taper, why on earth would a doctor NOT collaborate with them? This whole document seems to pit doctors against patients.

Tapering is more likely to be successful when patients collaborate in the taper.

Include patients in decisions, such as which medication will be decreased first and how quickly tapering will occur.

Nowhere do they allow a patient to “respectfully decline” the “offer” to be tapered, so “including patients in decisions” makes no sense.

No matter how strongly a patient objects, how well the opioids are working, how few side effects appear, and how unlikely the patient is to become addicted, the doctor has full control and is allowed to force the patient to taper no matter what.

Individualize the Taper Rate 

When opioid dosage is reduced, a taper slow enough to minimize opioid withdrawal symptoms and signsviii should be used. Tapering plans should be individualized based on patient goals and concerns.

Well, it’s my concern that my pain will increase and make me unable to do much more than lie around on the couch all day. The goal of patients is to remain active enough to avoid the problems of further deconditioning, so such a taper is never “based on patient goals and concerns”.

The longer the duration of previous opioid therapy, the longer the taper may take. Common tapers involve dose reduction of  % to % every weeks

Tapers may be considered successful as long as the patient is making progress, however slowly, towards a goal of reaching a safer dose,  or if the dose is reduced to the minimal dose needed. 

Treat Symptoms of Opioid Withdrawal

Expectation management is an important aspect of counseling patients through withdrawal. 

It seems they think our “expectations”, like to achieve some reasonably effective pain relief, can just be counseled away.

Significant opioid withdrawal symptoms may indicate a need to pause or slow the taper rate. 

In this whole document, only withdrawal symptoms are considered a valid reason to pause or slow down the taper, not the symptom of pain that arise when we are stripped of effective pain relief.

Some symptoms (e.g., dysphoria, insomnia, irritability, increased pain) can take weeks to months to resolve. 

Provide Behavioral Health Support

Make sure patients receive appropriate psychosocial support. ask how you can support the patient. 

Acknowledge patient fears about tapering. While motives for tapering vary widely, fear is a common theme. Many patients fear stigma, withdrawal symptoms, pain, and/or abandonment.  

Tell patients “i know you can do this” or “i’ll stick by you through this.” make yourself or a team member available to the patient to provide support, if needed. Let patients know that while pain might get worse at first, many people have improved function without worse pain after tapering opioids.

It seems downright insulting to ask a medical doctor to utter such falsely reassuring nonsense. Will they be present all night when the patient cannot sleep due to their pain? Will they be present when the patient has to decline social invitations due to their pain? Where are they when a patient is rolling around in agony with muscle spasms?

I’d hope doctors have enough self-respect and respect of their patients to say something more substantial and true, like “the government/my medical group/my boss is making me do this, even though I know you need this medication, but the government is forcing me to taper you.”

However, doctors are unlikely to say this truth because they can’t bring themselves to admit someone else with more power is telling them what to do.

It’s ironic that their need to maintain a superior posture ends up making them take the blame for tapers that may not even be under their control these days.

The “corporatization” of our healthcare system treats doctors like generic “employees”, as no one special or passion-driven to help people.

Watch closely for signs of anxiety, depression, suicidal ideation, and opioid use disorder and offer support or referral as needed.

Collaborate with mental health providers and with other specialists as needed to optimize psychosocial support for anxiety related to the taper.

 In other words, do absolutely anything except restart opioids, no matter how badly the patient has to suffer without them. Nobody considers it a risk the patients were left in pain

Special Populations

If patients experience unanticipated challenges to tapering, such as

  • inability to make progress despite intention to taper or
  • opioid-related harm,

assess for opioid use disorder using DSM-5 criteria.

This is just plain cruel. I’ve occasionally tried to taper myself down and have run into the completely “anticipated challenges” of increasing pain and decreasing function. That convinced me I need to keep taking these medications to preserve some quality of life.

And how can “opioid-related harm” result from tapering opioids? It seems these policymakers will go to any lengths to blame opioids for everything that doesn’t work the way they would like.

If patients on high opioid dosages are unable to taper despite worsening pain and/or function with opioids, whether or not opioid use disorder criteria are met, consider transitioning to buprenorphine.

Buprenorphine is a partial opioid agonist that can treat pain as well as opioid use disorder and has other properties that may be helpful,  including less opioid-induced hyperalgesia and easier withdrawal than full mu-agonist opioids, and less respiratory depression than other long-acting opioids.

Though touted throughout this article as a complete solution to both addiction and pain, buprenorphine is far from safe, especially for pain patients:

Buprenorphine can then be continued or tapered gradually. Transitioning from full-agonist opioids requires attention to timing of the initial buprenorphine dose to avoid precipitating withdrawal.

Closely monitor patients who are unable or unwilling to taper and who continue on high-dose or otherwise high-risk opioid regimens.

This is a joke: Patients have zero control over their doses because a doctor must prescribe them.

Mitigate overdose risk (e.g., provide overdose education and naloxone). Use periodic and strategic motivational questions and statements to encourage movement toward appropriate therapeutic changes.

 

4 thoughts on “HHS Guidance for Dosage Reduction

  1. canarensis

    This sounds exactly as if it was written by or for Oregon’s Taper Task Farce. All along, they have stuck rigidly with the intention & assumption that taper to zero will happen, must happen, no matter what. No amount of contradictory facts, evidence, testimony (expert & patient) can claw past their adamantine wall of certainty. It makes me absolutely enraged (which, of course, merely proves that I’m an hysterical over-reacting drug addict).

    And I always love it when they throw in the “safe and effective nonopioid treatments should be integrated into patients’ pain management plans.” As if we all haven’t already spent all our savings & then some trying nonopioid treatments & discovered that there IS no effective nonopioid treatments…that’s generally how we ended up on opioids & broke in the first place. Even before the national propaganda campaign (worthy of Goebbels), getting & staying on opioids has never been fun. Even when they were supposedly handed out by the bucketful to anyone who even mentioned the word “pain,” I sure never found it easy or pleasant to get them, nor was I treated with anything but abuse & suspicion by everyone except my former doc (retired 2 years ago), whom I saw for over 15 years. And “Use accessible, affordable nonpharmacologic and nonopioid pharmacologic treatments” …riiiight. Newsflash: they are expensive, almost never covered by insurance*, & they DO NOT WORK for most people. This asininity of pretending that music therapy and epilepsy drugs work as well as opioids is so counter to facts & to logic that I often feel like I am being gaslighted –& effectively gaslighted…these nutjobs really are making me lose my mind as well as my meds.

    And this business of pushing buprenorphine is insane…like the problems you write about, from all accounts, it’s MUCH harder to get off than other opioids, it’s a commonly abused recreational drug (which seems to sorta negate the ‘it’s the safe & non-recreational alternative’ narrative), & doesn’t work much for pain anyway.

    It’s a “naturalistic experiment” (a phrase the Oregon Extremists have officially used to describe the forced removal of people with back & spine conditions off opioids (2+ years ago) & the coming forced tapers of everybody else. Yet there is ZERO followup, they have no idea what impact of the forced-to-zero had on the back/spine people, in fact they don’t even know how many people were impacted then & will be impacted by the blanket removal of opioids. It’s really an experiment to see how high levels of chronic rage affects the health of people who were doing fine on their opioid therapy. That “adverse affect,” & increased pain & decreased functionality & QOL & skyrocketing BP & suicidal depression are apparently fine, as long as they’re caused by the removal of opioids.

    Mama, please let me wake from this nightmare….

    *tho the Oregon Extremists are pushing hard for them to be covered…many of them are acupuncturists, chiros, etc, who are trying to force Medicaid & other insurances to cover….acupuncture, chiropractic, etc. Gee, no conflict of interest there! They said this summer that they’d look into “possible” conflicts of interest…sometime soon. Eventually. After they cast the forced tapers in stone. More than 2 years into the process.

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      If I didn’t have such a great doctor myself, it would be easy to forget there are still some good ones hanging in there, braving censure and harassment to prescribe opioids if that’s what their patients need. I feel some degree of “survivors guilt”

      Liked by 1 person

      Reply
      1. canarensis

        I understand the survivors guilt…I try to focus on the fortunate few & feel glad that SOMEbody’s getting decent care. I hope it means there’s a better chance that this insanity will turn around, than if all the good ones got thrown in the slammer or quit. I am (for now at least) able to get a fairly low dose of tramadol (even got it from a new doc!), but it’s sure better than nothing. I also feel bad when I talk to people who are in worse pain than I am & have been cut off completely. Tho often rather than feeling guilty or hopeful, my primary gut response is rage that people are being deliberately, medically tortured. The anger really takes over when I talk to people who’ve had surgery & been denied all pain meds. Unnecessary torture in the short run & greatly increased likelihood of developing chronic pain from it…talk about a double whammy.

        Liked by 1 person

        Reply
  2. Kathy C

    Truly appalling, especially when many patients were just dumped by their doctors a few years ago, when the lies and propaganda reached a fever pitch. “Tapering” just sounds better than what they actually did, left patients in agony, and portrayed them all as addicts. At least they were able to make a lot of money from it all. If we had any accountability at all in this country the CDC would have a lot of explaining to do.

    Liked by 1 person

    Reply

Other thoughts?

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.