Opioids: A Guide to Tapering and Discontinuation
Healthesystems clinicians reviewed evidence-based guidelines to assemble this reference for tapering and discontinuing opioid therapy.
Long-term opioid use often results in well-documented risks for the injured worker, payer and employer that include dependence, disability and high costs. In many cases, clinicians at a PBM can work with a prescriber to taper and discontinue opioid therapy and minimize or eliminate associated risks. There is limited evidence to support a specific rate of tapering or tapering protocol; however, best practices, recommendations and considerations were captured to create this resource.
|The patient is taking high doses of opioids, regardless of whether they are long-acting or immediate-release formulations. Depending on the guidelines followed, high doses refer to daily morphine equivalent doses (MED) over 50-120. The 2014 opioid guideline developed by the American College of Occupational and Environmental Medicine (ACOEM) reflects the most current evidence and identifies 50 MED as the maximum recommended daily MED.||The patient shows no improvement in functional gains despite continued therapy.||The patient’s pain has increased (hyperalgesia) or shows no modification despite dose increases.1|
Discontinuation of opioid therapy is an intensely individualized process that depends largely on patient-specific factors. No single method of tapering works best, although all tapering protocols recommend against the abrupt discontinuation of opioid therapy. Here are some considerations to help make the tapering process as successful as possible.
Tapering protocols range from a slow protocol of 10 percent per week for an injured worker without comorbid substance abuse or psychiatric disorders,2 to a more rapid reduction of 25 to 50 percent every few days.
Anecdotal clinical evidence suggests that the initial dose reduction can be more rapid with high doses over 200mg of morphine equivalent per day.3 Once low daily doses are reached, a slower protocol may be required due to a higher incidence of withdrawal symptoms.
Withdrawal from opioid analgesics is a potentially unpleasant experience. Symptoms often include:
- gastrointestinal discomfort such as nausea, vomiting and diarrhea
- muscle pain
- runny nose
- teary eyes
- excessive salivation
- increased blood pressure4
These symptoms should not be treated with opioids or benzodiazepines. Clinical studies indicate they are generally not life threatening and can be avoided or minimized with appropriate dose adjustments throughout the tapering process.5
It is vital that clinicians continue to treat patients withdrawing from chronic opioid therapy for pain and other comorbidities that may include substance abuse or psychiatric disorders. Pain management can be continued with NSAIDs, acetaminophen, neuropathic coanalgesics and topical agents such as lidocaine and capsaicin.6
Non-pharmacological services can promote successful dose tapering. Referral to a mental health professional for cognitive behavior therapy (CBT) can assuage the anxiety that often accompanies the tapering process. Treatment with CBT to teach coping skills in support of the tapering process will not necessarily result in a psychiatric diagnosis. Therefore, other psychological services may not necessarily be compensable.
Aquatic and physical therapy are recommended to increase functionality and prevent muscle stiffness and pain.7 Some patients can benefit from adding occupational therapy, vocational rehabilitation, massage, acupuncture and chiropractic services during tapering.
It is important to continually evaluate patients for comorbid conditions and mental disorders that could include depression and elevated risk for drug abuse or diversion.
Consider referring high-risk patients to a multidisciplinary pain management center where tapering can be closely monitored. Patients with an opioid addiction may not be candidates for outpatient tapering and may require a referral to a detoxification program.
Comprehensive Pain Management Centers
Reputable comprehensive pain management centers offer an option to effectively treat pain and reduce opioid use. They address the physical and psychological aspects of chronic opioid use using a team approach involving pain management and addiction specialists, psychologists, physical therapists and occupational therapists. Payers can look to the American Pain Society for a list of 35 clinics awarded its Clinical Center of Excellence in Pain Management designation. The designation signifies that each facility offers evidence-based, multidisciplinary, multimodal treatment.8 These centers often provide a wide range of multidisciplinary services that may include yoga, biofeedback, acupuncture and chiropractor services, as well as vocational and work preparation programs. Success rates will vary, but one center reported that 70 percent of patients treated in 2010 returned to work within a year.9
For a list of centers recognized by the American Pain Society, visit http://tiny.cc/painmanagementcenter
Payer and prescribers can take a number of actions in advance of commencing a tapering protocol to increase the likelihood of success.
Payers can request a copy of several documents to gain a clear understanding of what is happening with the patient.
The physician’s written treatment plan should reflect findings from a physical exam and provide a plan for starting and stopping opioid therapy. The treatment plan should consider the patient’s mental state, functional abilities, activities of daily living, daily social and work activities as well as pain when creating realistic pain management goals.
A prescriber/patient pain management agreement outlines the goals of therapies and responsibilities of each party, and should include a stipulation for using a single prescriber and single pharmacy for pain medications,
The physician’s plan for opioid discontinuation should indicate the steps currently planned and a status on each if the plan is in progress.
Prescribers can reduce use of multiple drug therapies (polypharmacy) by streamlining the number of medications prescribed. This can reduce side effects and promote adherence to a medication regimen.
Prescribers can optimize alternative pain management strategies such as neuropathic agents, non-opioid analgesics, skeletal muscle relaxants and treatment for psychiatric comorbidities.
Prescribers can provide the patient and caregivers with instructions regarding the tapering process to minimize anxiety.