A Practical Approach to Opioid Weaning in the Midst of an Opioid Crisis – Pain Medicine News – by Mary Milano Carter, MS, APRN-BC, RN-BC – Sep 2019
The expanse of chronic pain in the United States is incredible. According to U.S. government statistics, pain affects more people than diabetes, coronary heart disease or cancer.
Low back pain gets the gold medal here, affecting 27% of individuals with chronic pain, per the National Institutes of Health.
Approximately 26 million Americans between 20 and 64 years of age experience frequent episodes of low back pain, and it is the leading cause of disability in Americans under 45 years of age, according to the AAPM.
As providers, we struggled to treat our patients’ complaints of debilitating pain, and sales of prescription opioids quadrupled between 1999 and 2014.
Treating benign pain with opioids became an accepted part of the treatment plan, keeping in mind the need to satisfy the Joint Commission’s standards for pain management.
In 2016, the “CDC Guideline for Prescribing Opioids for Chronic Pain” stated that opioids should not be prescribed as first-line treatment for chronic pain, and that prescriptions should be kept to 90 mg of morphine or less daily, or the equivalent in another opioid
No, it did NOT say to keep rx at 90mg or less – it merely said to be more cautious.
Unfortunately, a guideline that was aimed at primary care providers became a standard of care to insurance companies. Providers had to comply with weaning patients on opioids to satisfy the CDC guideline
But the guideline never mentioned anything about weaning. In fact, it said nothing about patients already taking opioids.
It’s all the other people/agencies meddling with our meidcal care that unilaterally decided to wean current patients.
Pain management providers have been adept at weaning patients from opioids due to severe side effects, patient noncompliance with treatment, unsafe patient behaviors, lack of efficacy of the medication or just simply patient desire.
But most patient being weaned don’t exhibit these wigns of opioid use disorder. It seems Ms Carter is saying that while they’ve always had to wean people who had problems with using opioids or their efficacy, now they “had to” wean patients for no other reason than to satisfy bureacracy or managers they are working under.
The Process of Tapering
How long does it take for a patient to become opioid tolerant?
The FDA definition is a patient taking 60 mg of oral morphine daily, or the equivalent of that in another opioid, for at least one week.
If a patient discontinues abruptly or is tapered down rapidly, withdrawal symptoms can occur.
The National Institute on Drug Abuse states that the length of withdrawal symptoms is dependent on
- how long the drug was taken,
- the dosage of the drug,
- the half-life of the drug,
- the patient’s age and
And NIDA (the agency with extensive history and expertise on drug abuse) helpfully explains the journey through withdrawal:
- The typical onset of withdrawal is approximately 12 hours, starting with myalgias and excessive yawning.
- By day 2, hyperhidrosis, anorexia, diarrhea, runny nose, and anxiety and panic attacks can occur.
- By the third or fourth day, the patient can experience abdominal cramping and vomiting while the myalgias begin to subside.
- By days 5 to 6, most of the physical symptoms will resolve, but the psychological symptoms can be long-lasting (Table).
Table. Opioid Withdrawal Symptoms
When initiating an opioid taper, alert the patient that the process typically takes two weeks to six months—and sometimes up to 24 months, depending on opioid usage.
The total daily dose of opioids can be reduced 10% to 20% every one to two weeks, and reduced up to 50% at a time if the dosage is low or truly as needed.
Dies this mean opioids were used when they were *not* needed?
If the dose of a medication is taken truly “as needed”, this statement means the patient is suffering from symptoms that medication can ameliorate.
This seems a clear medical reason to continue the medication. Otherwise, a doctor is literally deprescribing a medicine that was medically needed.
When the total daily dose becomes very low, it should be reduced by 5% at a time.
It is important to monitor the patient closely for withdrawal symptoms, and individualize the plan of care.
When performing an opioid taper without a medical reason, only because of outside influences, how can that be individualized? When a patient needs a medication, treating them as an individual would mean continuing to prescribe the needed medication.
If the patient is reporting withdrawal symptoms, you can use the Clinical Opiate Withdrawal Scale.
Eleven symptoms are graded and tallied, and total score will indicate mild to severe opioid withdrawal (Figure).
Figure. Clinical Opiate Withdrawal Scale.
Based on J Psychoactive Drugs. 2003;35(2):253-259.
Medication therapies to assist with weaning and withdrawing opioids include:
- lonidine (physical withdrawal symptoms, decreases sympathetic activity)
– mg po bid; Catapres TTS1 patch
- nonsteroidal anti-inflammatory drugs/acetaminophen (pain)
- loperamide (diarrhea)
- melatonin or trazodone (sleep)
- prochlorperazine (nausea and vomiting)
- hydroxyzine (anxiety)
- oxybutynin (sweats)
The patient should be reassessed every three to seven days. It is not recommended to treat withdrawal symptoms with other opioids or benzodiazepines.
How is a patient, crippled by pain, going to get to the doctor every 3 to 7 days? How can a disabled patient afford so many appointments?
Most of the suggested drugs have already been prescribed to pain patients to lower the dose of opioids needed.
There are also adjuvant therapies to assist with opioid weaning.
Nondrug management can include
- support groups and counseling,
What if your pain doesn’t respond to talk therapy because it has a physical cause?
- Referrals to detox/addiction medicine/psychiatry,
No matter how prettily they dress it up we see here that they think we’re all more addicted than in pain.
- nutrition and hydration counseling,
So now our disabling chronic pain might be due to not drinking enough water? To not eating the right food?
What if your sleep is horrible *because of* your pain? What if you can’t sleep because you’re no longer given proper pain relief?
- relaxation and meditation,
The modern “cure-all”: you’re hurting because you’re stressed and if you’d just learn to relax, you wouldn’t be having so much pain. Condescending, minimizing,
Now a medically trained doctor is expected to promote “mystical” alternative therapies? Seriously?
If a patient has pain severe enough to need opioids, aromatherapy will not be effective.
What if you can’t exercise *because of* your pain? What if tapering causes your pain to increase, and then you can no longer exercise? (that’s my case: the less opioid, the more pain, the less exercise – I doubt I’m unique in that aspect.)
Also, most of these non-opioid therapies are already being used on pain patients in addition to their opioids.
The American Society of Addiction Medicine also has guidelines for opioid withdrawal.
Again, patients are assumed to be addicted.
Recommendations include the use of:
- clonidine to support opioid withdrawal;
- methadone for patients who may benefit from daily dosing;
- oral buprenorphine, initiated after withdrawal, although it has poor medication adherence;
- oral buprenorphine-naloxone, initiated until 12 to 18 hours after the last dose of a short-acting agonist; and
- naltrexone for extended-release injectable suspension (Vivitrol, Alkermes) for those with difficulty adhering to oral daily doses.
In conclusion, clinicians should be aware that there are many options for safely weaning patients from chronic opioid therapy.
I wish they’d explain more about the basic assumption that all patients on opioids MUST be tapered.
There are many patients who use opioids responsibly and only use them as needed for pain, but they are never mentioned. It’s as though it’s no longer legal to treat legitimate pain with effective medication.
Author: Ms. Carter is a member of the Pain Medicine News editorial advisory board.
Director of Nursing Education, Chronic Pain Service/Anesthesiology, North Shore University Hospital, Manhasset, N.Y.