Health Officials Urge Caution in Reducing Opioids for Pain Patients
"In a newly published guide, federal health officials say doctors “should never abandon” pain patients and warn of acute withdrawal and other risks.
The new tapering guide goes deeper, detailing the potential harms to patients who abruptly stop taking opioids and laying out factors to consider and steps to take before starting a taper."
Cutting patients off suddenly can not only leave them angry, but also in danger. Cutting patients off can leave providers with significant liability. If you are suddenly no longer able to prescribe opiates for a patient or they need to stop abruptly, prescribing a medical detox can be one of the safest option.
"The new guide states that doctors “should never abandon” pain patients, and warns of risks including “acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, and patients seeking opioids from high-risk sources.
It says that opioid doses are typically reduced by between 5 and 20 percent a week, but that slower tapers are often better tolerated, partly because they are less likely to trigger withdrawal symptoms."
It is also important to consider if a patient really needs to be on opiates at all.
"But the guide also lays out reasons to consider tapering patients off opioids, stressing that the benefits of staying on the drugs need to outweigh the risks. Those risks are substantial, including addiction and overdose, but many chronic pain patients and their doctors say they have been able to stay on high doses of opioids and function competently.
A growing body of research has found that opioids are usually not the best treatment for long-term pain other than from cancer and certain other conditions, and that over-the-counter ibuprofen, physical therapy and other approaches may work better, with far fewer risks."
The new recommendations do not support abrupt tapering or sudden discontinuation of opioids.
Recommends: "Follow up regularly with patients to determine whether opioids are meeting treatment goals and whether opioids can be reduced to lower dosage or discontinued."
We recommend all providers monitor their patients regularly to see if opioids are necessary, if the dose could be lower, or if there is any potential for abuse.
"Consider tapering to a reduced opioid dosage or tapering and discontinuing opioid therapy when your patient:
• requests dosage reduction
• does not have clinically meaningful improvement in pain and function (e.g., at least 30% improvement on the 3-item PEG scale)
• is on dosages ≥ 50 MME*/day without bene t or opioids are combined with benzodiazepines
• shows signs of substance use disorder (e.g. work or family problems related to opioid use, difficulty controlling use)
• experiences overdose or other serious adverse event
• shows early warning signs for overdose risk such as confusion, sedation, or slurred speech
*morphine milligram equivalents
If you are unable to monitor a patient (provide supporting medications to help handle withdrawal symptoms, provide accountability when reducing the dose, and give therapeutic support to handle triggers and mental dependence) during a long taper, or your patients are not able to complete a long self-taper protocol, please consider referring your patients to a medical detox treatment.
A doctor prescribed taper can last months, and gives the patient a large amount of responsibility for completing the taper.
A medical detox for opiates can be complete in as few as 7 days and the treatment manages withdrawal symptoms, provides support & accountability, and counseling to address any psychological concerns.
We do not taper our patients off of their opiate prescription. We use a medication substitute to detox and taper the patient.
Our doctor has 27 years of experience & we refer to our inpatient program for any medical complications.
We meet with patient daily to help them process everything they are experiencing throughout the detox and we schedule aftercare for our patients to provide continued support.
At each daily appointment we provide accountability and encouragement. Our nurses give patients hope and let them know they are not alone.
Consider tapering to a reduced opioid dosage, or tapering and discontinuing opioid therapy, when:
• Pain improves
• The patient receives treatment expected to improve pain
• The patient requests dosage reduction or discontinuation
• Pain and function are not meaningfully improved
• The patient is receiving higher opioid doses without evidence of benefit from the higher dose
• The patient has current evidence of opioid misuse
• The patient experiences side effects that diminish quality of life or impair function
• The patient experiences an overdose or other serious event (e.g., hospitalization, injury) or has warning signs for an impending event such as confusion, sedation, or slurred speech
• The patient is receiving medications (e.g., benzodiazepines) or has medical conditions (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) that increase
risk for adverse outcomes
• The patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear
More rapid tapers (e.g., over 2-3 weeks16) might be needed for patient safety when the risks of continuing the opioid outweigh the risks of a rapid taper (e.g., in the case of a severe adverse event such as overdose).
Treat symptoms of opioid withdrawal
Provide behavioral health support