HHS Guide for Clinicians on Opioid Dosage Reduction

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics.pdfSeptember 2019

This is the federal document mentioned in the previous post.

This HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-T erm Opioid Analgesics provides advice to clinicians who are contemplating or initiating a reduction in opioid dosage or discontinuation of long-term opioid therapy for chronic pain.

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.

This guide reiterates that benefit/risk calculation over and over as though it’s a special procedure for opioids when it’s what doctors have always been doing. 

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

In each case the clinician should review the risks and benefits of the current therapy with the patient, and decide if tapering is appropriate based on individual circumstances.

More specific guidance follows, compiled from published guidelines (the CDC Guideline for Prescribing Opioids for Chronic Pain and the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain) and from practices endorsed in the peerreviewed literature.

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

  • Pain improves  
  • The patient receives treatment expected to improve pain
  • The patient requests dosage reduction or discontinuation
  • Pain and function are not meaningfully improved
  • The patient is receiving higher opioid doses without evidence of benefit from the higher dose
  • The patient has current evidence of opioid misuse
  • The patient experiences side effects that diminish quality of life or impair function
  • 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.
  • 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
  • The patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear.

These are all common sense criteria. The problem is in their application by anti-opioid doctors.

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

More specific guidance follows, compiled from published guidelines (the CDC Guideline for Prescribing Opioids for Chronic Pain 2 and the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain 3 ) and from practices endorsed in the peerreviewed literature.

Important considerations prior to deciding to taper

Overall, following voluntary reduction of long-term opioid dosages, many patients report improvements in function, sleep, anxiety, and mood without worsening pain or even with decreased pain levels.

Decisions to continue or reduce opioids for pain should be based on individual patient needs. 

This is all we’re really asking for. We want some treatment, therapy, or medication that reduces our daily pain to a manageable level in a manner that’s effective for us as individuals, not just something printed in a fancy sales brochure or some therapy that’s touted by its “true believers”, but some treatment that works for us specifically, relieves our pain enough that we can participate in life instead of watching from the sidelines.

There are as many different pains as there are different sensations and situations, so it seems absurd to standardize its treatment.

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).  

Opioids should always and exclusively be prescribed when “warranted” which just means there should be a good reason for taking them, which essentially means that benefits are more than costs, which is the way all of “medicine” operates.

The CDC Guideline for Prescribing Opioids for Chronic Pain does not recommend opioid discontinuation when benefits of opioids outweigh risks.

The problem lies in how differently a patient experiences the risk/benefit than how a doctor perceives the patient’s risks and benefits.

Avoid misinterpreting cautionary dosage thresholds as mandates for dose reduction.  While, for example, the CDC Guideline recommends avoiding or carefully justifying increasing dosages above 90 MME/day, it does not recommend abruptly reducing opioids from higher dosages.

The Guideline never set dose limits, just “cautionary” limits that, in themselves, make good sense. But it quantified and categorized dose limits that zealots seized on as absolute limits for every patient.

Consider individual patient situations.

Avoid dismissing patients from care.

Important steps prior to initiating a taper

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

Use accessible, affordable nonpharmacologic and nonopioid pharmacologic tr eatments .

I’m impressed that they mention “affordability” – it’s the first time I’m seeing this concern officially recognized.

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

The reason they are “receiving long-term opioid therapy” is probably because their pain is too severe and doesn’t respond to other treatments.

Other patients report increased pain, insomnia, anxiety, and depression.

This is the first time I’ve seen this acknowledged in a government guideline.

Depressive symptoms predict taper dropout.

Advise patients that there is an increased risk for overdose on abrupt return to a previously prescribed higher dose. Strongly caution that it takes as little as a week to lose tolerance and that there is a risk of overdose if they return to their original dose . Provide opioid overdose education and consider offering naloxone.

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.

This is all just what the “practice of medicine” is all about: a partnership between patient and doctor to facilitate healing. But now that it’s all about checklists and timers and endless screens to click through, such old-fashioned directives seem to be necessary.

If the current opioid regimen does not put the patient at imminent risk, tapering does not need to occur immediately.

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.

Yet, this is exactly what happened in many places: forced opioid tapers for no medical reason, only administrative edicts.

Individualize the taper rate

At times, tapers might have to be paused and restarted again when the patient is ready.

The longer the duration of previous opioid therapy, the longer the taper may take. Common tapers involve dose reduction of 5% to 20% every 4 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.

Shouldn’t the dose of any medication always be the minimum a patient needs?

Other thoughts?

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