Start a Dialogue About Tapering Chronic Opioids

You'll hear debate about when and how to taper chronic opioids.

CDC experts say that some opioid policies, such as from payers or states, go beyond the guidelines...leading to unintended consequences.

For example, CDC discourages increasing opioid doses to 90 morphine milligram equivalents (MME)/day or more...for chronic noncancer pain. But this doesn't mean forcing tapers or suddenly stopping high opioid doses.

And FDA will now require tapering guidance in opioid labels...due to concerns that abruptly stopping is leading to illicit use or even suicide.

Tailor care to your patient while considering the guidelines.

Identify patients where opioid risks exceed benefits...those on high doses, with side effects, etc. Help them buy in to a slow taper.

Ask patients how well their chronic opioid is working. Educate that the goal is not complete pain relief...but to improve pain AND function.

Discuss opioid downsides...cognitive slowing, constipation, etc. Patients may not realize chronic use can cause hyperalgesia, an increased sensitivity to pain...or low hormone levels and reduced libido or energy.

Evidence suggests tapering to lower doses improves quality of life and function...and pain doesn't usually worsen. In fact, it may improve.

Emphasize alternatives...non-opioids, physical therapy, etc.

Reassure that any withdrawal symptoms are minimal and manageable with a slow taper...which can be further slowed or paused if needed. Plus symptoms can be eased with other meds...loperamide, clonidine, etc.

Work with prescribers to individualize tapers. For instance, suggest reducing the daily opioid dose by about 10% every 1 to 2 weeks...or slower, such as monthly, if patients have been on opioids for years.

Request lower-strength Rxs if needed for flexibility. For example, to taper morphine extended-release 120 mg/day, suggest using 15 mg ER one tab of the daily dose can be dropped at each step down.

Expect some chronic pain patients to have trouble tapering off opioids completely. Success may be settling on a lower opioid dose.

Refer patients with opioid use disorder for medication-assisted treatment with buprenorphine/naloxone, etc.

Continue to recommend naloxone for patients at risk of overdose.

Use our chart, Opioid Tapering: Tips for Success, for key talking points...and practical guidance for tapering and monitoring.

Key References

  • N Engl J Med Published online Apr 24, 2019; doi:10.1056/NEJMp1904190
  • Pain Med 2019;20(3):429-33
  • Pain Med 2019;20(4):724-35
  • Mayo Clin Proc 2015;90(6):828-42
Pharmacist's Letter. June 2019, No. 350601

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