-
Determine appropriateness of opioid reduction - Consider reduction if: pain improves, higher doses don’t improve pain/function, side effects ↓function/QOL, OD/serious event, misuse suspected, ↑risk from concurrent comorbidities1 or meds (eg, BZD2), benefit vs harm unclear after long-term tx, or at pt request
- Avoid reduction if cancer-related/end-of-life pain, or when analgesia benefits outweigh risk. Avoid if physically dependent pt is noncollaborative, given ↑risk of w/d & serious adverse events
Weigh risk-benefit of opioid reduction - Benefits: improved function, sleep, anxiety, mood; stable or even reduced pain
- Risks: (↑w/ rapid taper, physical dependence, noncollaborative pt) acute w/d, pain exac, insomnia, anxiety/depression, psych distress, suicidality/self-harm, broken trust, high-risk/illicit opioid-seeking
Coordinate ongoing care, whether or not tapering; never abandon pt - Pain mgmt: Integrate safe, effective nonopioid & nonpharmacologic3,4 approaches
- Closely monitor pts unwilling/unable to taper: Offer OD education, naloxone, encouragement. Eval for opioid use disorder1 if misuse signs. If on high doses despite worse pain/function, consider transition to buprenorphine (even w/o opioid use disorder)
- Expert consult if: pregnancy (risks for spontaneous abortion/premature labor); serious mental illness/suicidal ideation; or if expertise needed from clinician familiar w/ buprenorphine initiation
Footnotes 1 HHS 2019. Risk from concurrent comorbidities: lung dz, sleep apnea, liver or kidney dz, fall risk, advanced age.
If opioid misuse signs: Assess for opioid use disorder according to DSM-5 criteria. If diagnosed, consider medication-assisted tx (eg, buprenorphine, etc).
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. October 2019. Free full-text PDF
2 VA 2016. BZD tapering guidance from VA. U.S. Department of Veterans Affairs. Benzodiazepine Risks Are You Aware of the Possible Risks from Taking Benzodiazepines? Provider Guide. October 2016. Free full text PDF
3 CDC 2016. Nonopioid tx and nonpharmacologic tx. Nonopioid Treatments for Chronic Pain. Principles of Chronic Pain Treatment. U.S. Department of Health and Human Services. April 27, 2016. Free full-text PDF
4 AHRQ 2018. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Evidence Summary. Comparative Effectiveness Review Number 209. June 2018. Free full-text PDF
-
Opioid use disorder diagnosis
Consider if misuse behavior signs or unanticipated challenges to tapering. If opioid use disorder diagnosed, arrange medication-assisted tx (buprenorphine, etc) DSM-51 definition: problematic use w/clinically significant impairment/distress in a 12-mo period. Mild=2-3, Mod=4-5, Severe=6+ of these: - Often taking larger amounts or over longer period than intended
- Persistent desire or unsuccessful efforts to cut down/control use
- Spending significant time obtaining/using/recovering from opioids
- Strong urge to use opioids
- Recurrent use interferes w/ work/school/home
- Continued use despite recurrent social/interpersonal problems from opioids
- Important activities reduced/given up due to use
- Recurrent use in physically hazardous situations
- Continued use despite recurrent physical/psych problems caused by substance
- Tolerance, defined as 1) need for markedly increased amounts to achieve intoxication/desired effect, or 2) markedly diminished effect using same amount2
- Withdrawal, defined as 1) characteristic opioid withdrawal syndrome, or 2) using opioids/related substance to relieve/avoid w/d sx2
Footnotes 1 HHS 2019. Based on DSM-5 criteria. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. October 2019. Free full-text PDF
2 HHS 2019. Doesn’t apply when opioids taken solely under appropriate medical supervision. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. October 2019. Free full-text PDF
-
Tapering strategy selection
No opioid use disorder diagnosis First assess/tx mental illness (anxiety, depression, PTSD). If on BZD, consider tapering - If serious mental illness, high suicide risk/ideation: behavioral health consult before taper
- If also on BZD: Coordinate gradual BZD taper1 to avoid BZD w/d (anxiety, hallucinations, sz, DT, rarely death)
Individualize nonabrupt taper, even if on high doses (>90 MME/d), via shared decision-making. Once min dose reached, ↑interval b/t doses, then d/c once interval 2 - Slower taper2 over mos/yrs: ↓by 5%-20% of original dose q4 wks. Better tolerated, esp w/ opioid use ≥1 year; longer opioid use warrants slower taper
- Faster taper2 over wks: ↓by 10% of original dose qwk until 30% of original dose reached; then ↓by 10% of remaining dose qwk. Consider if hx opioid use for wks/mos
- Rapid taper,2 eg, over 14-21 days: Though w/d may occur, use rapid taper if life-threatening/imminent risk, eg, signs of impending OD/serious event
- Ultra-rapid detox under anesthesia: Don’t use, due to substantial risks
Follow weekly, set expectations; monitor for w/d; pause/slow taper if needed; regularly re-eval risk-benefit & psycho/social support needs - Offer nonopioid & nonpharmacologic pain mgmt3,4 before/during taper
- Educate on & monitor for w/d sx
- Advise on OD risks if pt abruptly returns to previous higher dose;5 consider naloxone
- Success=any progress (even slow) or min dose reached
- If unable to taper: Consider opioid use disorder;6 if on high doses despite worse pain/function, consider transition to buprenorphine (even w/o opioid use disorder)
Footnotes 1 VA 2019. BZD tapering guidance available from VA. U.S. Department of Veterans Affairs. Benzodiazepine Risks Are You Aware of the Possible Risks from Taking Benzodiazepines? Provider Guide. Free full text PDF
2 VA 2016. Samples tapers available. Pain Management Opioid Taper Decision Tool. A VA Clinician's Guide. October 2016. Free full-text PDF
3 CDC 2016. Nonopioid tx and nonpharmacologic tx. Nonopioid Treatments for Chronic Pain. Principles of Chronic Pain Treatment. U.S. Department of Health and Human Services. April 27, 2016. Free full-text PDF
4 AHRQ 2018. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Evidence Summary. Comparative Effectiveness Review Number 209. June 2018. Free full-text PDF
5 HHS 2019. Tolerance can be lost after as little as 1 wk. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. October 2019. Free full-text PDF
6 HHS 2019. Assess via DSM-5 criteria. If diagnosed, consider medication-assisted tx (eg, buprenorphine, etc.) HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. October 2019. Free full-text PDF
Opioid use disorder diagnosis Arrange transition1 to medication-assisted tx (eg, buprenorphine) for opioid use disorder,2 assess/tx comorbid mental illness, use shared decision-making - Assess/tx comorbid mental illness (anxiety, depression, PTSD). If serious mental illness, high suicide risk/ideation: behavioral health consult before opioid taper. If also on BZD, coordinate gradual BZD taper3 to avoid BZD w/d (anxiety, hallucinations, sz, DT, rarely death)
- Transition2 to buprenorphine, which treats both opioid use disorder & pain, w/ better risk profile than opioids. If pregnant w/ opioid use disorder: Medication-assisted tx preferred over detoxification2
- Individualize continuation or gradual taper of buprenorphine, based on shared decision-making, risk-benefit eval
Set expectations, offer nonopioid tx, monitor for w/d sx; regularly re-eval risk-benefit & psycho/social support needs - Offer nonopioid & nonpharmacologic pain mgmt4,5
- Educate on & monitor for w/d sx (esp during transition)
- Advise on OD risks if pt abruptly returns to previous higher opioid dose;2 consider naloxone
Footnotes 1 Resources from SAMHSA: Buprenorphine Practitioner Locator, Opioid Treatment Program Directory. Accessed online 11/5/19
2 HHS 2019. Assess via DSM-5 criteria. If diagnosed, consider medication-assisted tx (eg, buprenorphine, etc).
Buprenorphine. Timing of initial dose important to avoid precipitating protracted w/d sx during transition; pt should be in mild-to-mod w/d prior to 1st buprenorphine dose.
Pregnancy. Opioid w/d risks include spontaneous abortion and premature labor.
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. October 2019. Free full-text PDF
3 VA 2016. BZD tapering guidance available from VA. U.S. Department of Veterans Affairs. Benzodiazepine Risks Are You Aware of the Possible Risks from Taking Benzodiazepines? Provider Guide. October 2016. Free full-text PDF
4 CDC 2016. Nonopioid tx and nonpharmacologic tx. Nonopioid Treatments for Chronic Pain. Principles of Chronic Pain Treatment. U.S. Department of Health and Human Services. April 27, 2016. Free full-text PDF
5 AHRQ 2018. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Evidence Summary. Comparative Effectiveness Review Number 209. June 2018. Free full-text PDF
-
Opioid withdrawal sx management
Monitor for sx; anticipate onset (hrs, days) based on opioid duration of action. - Anticipate sx duration. Early sx (anxiety restlessness, sweating, yawning, myalgia, diarrhea, cramping, etc) usually resolve in 5-10 days, may take longer. Other sx (dysphoria, insomnia, irritability, etc) may take wks/mos
- Autonomic sx (sweating, tachycardia): alpha-2 agonist (eg, clonidine)
- Myalgias: NSAIDs, acetaminophen, topical menthol/methyl salicylate
- Anxiety, dysphoria, lacrimation, rhinorrhea: hydroxyzine, diphenhydramine
- Sleep disturbance: trazadone, hydroxyzine, diphenhydramine
- Nausea: prochlorperazine, promethazine, ondansetron
- Abdominal cramping: dicyclomine
- Diarrhea: loperamide or bismuth subsalicylate
|
