Opioid Tapering

Welcome

Higher prescribed opioid dose is associated with increased risk of overdose, opioid use disorder, depression, fracture, motor vehicle accident, and suicide (Ann Int Med 2017; 167: 181-191).

Opioid tapering which results in dose reduction or discontinuation may decrease these risks and expert guidelines in the United States and Canada recommend tapering when risks outweigh benefits (CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 and The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain) however some approaches are more patient-centered than others.

This online module was designed as part of a Health Resources & Services Administration (HRSA) grant by faculty at East Tennessee State University Academic Health Science Center (ETSU AHSC) to assist primary care providers with opioid tapers. It provides background information, taper formatting, and links to helpful resources and references. Thank you for taking your time to complete this training and we hope it will benefit your patient care.

Please review the material below and on the subsequent pages then finish by completing the Post-Test. This online module should take about 1 hour to complete.

Thank you! Please contact Emily Flores, PharmD, BCPS with questions at florese@etsu.edu.

Objectives

After completing this online module, participants should be able to:

Identify patients that would benefit from opioid tapers
Construct and utilize opioid tapers for appropriate patients
Select and utilize appropriate non-opioid medications and modalities to manage pain

Treating America's Pain: Unintended Victims of the Opioid Crackdown, Part 1 – The SuicidesThe national opioid crisis propelled a crackdown on prescription painkillers, causing hundreds of doctors to abruptly reduce or completely cut off their patients’ prescriptions, leaving many among the estimated 20 million Americans who suffer from daily debilitating chronic pain to consider suicide. This is the story of the overlooked victims of America's opioid epidemic.

Treating America's Pain: Suicide Risk with Tapers

The decision to taper opioids is a balancing act. The process to taper opioids is a collaboration. There is risk in use and there is risk in lack of use.

Click on the image to the left or this link to watch this short video for perspective.

(6 minutes, 26 seconds)

Is opioid use patient-centered?

We should consider when we are assessing or prescribing therapy if it is the Right Patient, Right Drug, Right Dose, Right Route, Right Formulation, Right Time, Right Reason, and Right Duration. There are other medications and modalities for pain relief that do improve quality of life with less risk in the right patient.

Long-term opioid use may lead to ...

Opioid-induced hyperalgesia (chronic opioid exposure leading to increased sensitivity to pain)
Physical dependence
Constipation and nausea
Drowsiness and fatigue
Depressed mood
Sleep apnea / respiratory health issues
Lower testosterone and related complications
Lower estrogen and related complications

These risks are only some of the reasons to consider tapering

Consider tapering when ...

Patient has opioid side effects
Patient requests dose reduction
Patient does not have clinically meaningful improvement in pain and function
Patient is on >/= 50 MME (morphine milligram equivalents) per day without benefit (clinically meaningful improvement in pain and functioning)
Patient is on opioid is combined with benzodiazepine
Patient is not adherent to regimen or violates opioid use agreement
Patient shows signs of substance use disorder
Patient experiences overdose or other serious event
Patient shows early warning signs for overdose risk such as confusion, sedation, or slurred speech

Click here for: CDC Pocket-Guide: Tapering Opioids for Chronic Pain

What should we watch for when tapering?

Symptoms

Flu-like (sweating, chills, goose bumps, headache, generalized muscle and/or joint aches)
Fatigue, restlessness, anxiety, trouble sleeping, hallucination and/or tremor
Nausea, vomiting, abdominal cramps, and/or diarrhea
Increased heart rate and blood pressure

Timeline

Opioid withdrawal is not deadly in and of itself, though patients may feel quite bad depending on level of withdrawal.

Withdrawal symptoms generally start within 12-48 hours of the last dose, are worse in the first 1 to 4 days, and improve in 5 to 7 days.

Timeline and level of symptoms varies based on dose, duration, and patient.

There is higher risk of harm with withdrawal in pregnancy and opioid use disorder.

Tapers are typically NOT patient-centered if they

Are done too quickly (i.e. a decrease of 25-50% every few days)
Cause severe withdrawal symptoms
Lack close follow-up and adjustment
Are completed within a few weeks

Practice Identifying Patients ...

Should the following patients should be considered for opioid tapering?

Marta is a 34-year-old female who was first given Oxycodone for a kidney stone 3 years ago. Since then she has been in an abusive relationship leading to many physical injuries resulting in corrective procedures and multiple Oxycodone prescriptions such that she has been on Oxycodone 30mg four times daily for the past 6 months continuously. She is now living in a Women's Shelter. She tells you the Oxycodone is not helping anymore and though there are no new injuries and her last procedure was over 2 months ago, she requests dose titration.
- Yes
- No
Luka is a 72-year-old male who worked in the factory for 50+ years and has severe osteoarthritis. He has a history of two gastrointestinal bleeds attributed to nonsteroidal anti-inflammatory drug (NSAID) use. His current regimen is Acetaminophen 500mg po four times daily and Oxycontin 20 mg po twice daily. His only other medication is Hydrochlorothiazide 25mg po QAM. He has no history of falls and is able to ambulate unassisted. He lives alone and visits with grandchildren and neighbors regularly.
- Yes
- No
George is a 17-year-old male who received Oxycodone/Acetaminophen after an ACL repair and has been on it for 3 months now. Physical therapy is complete and full function has returned. George complains of newly developed depression and fatigue.
- Yes
- No
Lane is a 43-year-old female who works long hours at a grocery store. She has structural abnormalities in her back and a history of a couple of "failed" surgeries. She is now able to work full time while on MS Contin 20mg po three times daily. She tried other pain medications and regimens before the MS Contin with minimal relief. She is adherent with appointments and screenings and on a bowel regimen. Depression is treated with Cymbalta(R) but is now well controlled since she has also returned to work.
- Yes
- No

Key: While all patients should have their regimens reevaluated and optimized regularly, the ones above that have clear considerations for tapering are Marta and George.