Prescribing opioids in primary care: Safely starting, monitoring, and stopping
ABSTRACTChronic noncancer pain is common and often managed in the outpatient setting with chronic opioid therapy, even though the efficacy of this approach is uncertain and adverse effects are common. Some patients report meaningful benefit from opioids, but prescription drug abuse has reached epidemic proportions, and many suffer harm from opioid misuse, abuse, and diversion. Primary care providers and their care teams often struggle to balance these risks and benefits with little outside support. The authors review common challenges when starting, monitoring, and discontinuing opioids, and offer strategies for risk-reduction and patient communication.
KEY POINTS
- Predicting which patients will benefit and which ones will be harmed is difficult. We generally recommend a conservative approach to starting opioid treatment.
- Providers must periodically reassess the safety and efficacy of opioid therapy to be sure it is still indicated.
- Monitoring should be transparent and consistent. By framing monitoring in terms of safety and employing it universally, providers can minimize miscommunication and accidental stigmatization.
- When opioids are no longer safe or effective, they should be stopped. The decision can be difficult for the patient and the provider.
DISCONTINUING OPIOIDS
When opioids are no longer safe or effective, they should be stopped. The decision can be difficult for both the patient and provider, and a certain degree of equanimity is needed to approach it rationally.
Strong indications for discontinuation
Respiratory depression, cognitive impairment, falls, and motor vehicle accidents mean harm is already apparent. At a minimum, dose reduction is warranted and discontinuation should be strongly considered. Similarly, overdose (intentional or accidental) and active suicidal ideation contraindicate ongoing opioid prescribing unless the ongoing risk can be decisively mitigated.
Certain aberrant behaviors such as prescription forgery or theft, threats of violence to obtain analgesics, and diversion (transfer of the drug to another person for nonmedical use) also warrant immediate discontinuation. Continuing to prescribe an opioid while knowing diversion is taking place may be a violation of federal or state law or both.40
Another reason to stop is failure to achieve the expected benefit from chronic opioid therapy (ie, agreed-upon functional goals) despite appropriate dose adjustment. In these cases, ongoing risk by definition outweighs observed benefit.
Relative indications for discontinuation
Opioid therapy has many potential adverse effects. Depending on the severity and duration of the symptom and its response to either dose reduction or adjunctive management, opioids may need to be discontinued.
For example, pruritus, constipation, urinary retention, nausea, sedation, and sexual dysfunction may all be reasons to stop chronic opioid therapy. Similarly, chronic opioid therapy may paradoxically worsen pain in some susceptible patients, a complication known as opioid-induced hyperalgesia; in these cases, tapering off opioids should be considered as well.41 Aberrant behaviors should prompt reconsideration of chronic opioid therapy; these include hazardous alcohol consumption, use of illicit drugs, pill hoarding, and use of opioids in a manner different than intended by the prescriber.
Another relative indication for discontinuation is receipt of controlled substances from other providers. A well-written controlled substance agreement and adequate counseling may help mitigate this risk; poor communication between providers, lack of integration of electronic medical record systems, urgent or emergency room care, and poor health literacy may all lead to redundant prescribing in some circumstances. While unintentional use of controlled substances from different providers is no less dangerous than intentional misuse, the specifics of each case need to be considered before opioids are reflexively discontinued.
How to discontinue opioids
In most cases, opioids should be tapered to reduce the risk and severity of withdrawal symptoms. Decreasing the dose by 10% of the original dose per week is usually well tolerated with minimal adverse effects.42 Tapering can be done much faster, and numerous rapid detoxification protocols are available. In general, a patient needs 20% of the previous day’s dose to prevent withdrawal symptoms.43
Withdrawal symptoms are rarely life-threatening but can be very uncomfortable. Some providers add clonidine to attenuate associated autonomic symptoms such as hypertension, nausea, cramps, diaphoresis, and tachycardia if they occur. Other adjunctive medications include nonsteroidal anti-inflammatory drugs for body aches, antiemetics for nausea and vomiting, bismuth subsalicylate for diarrhea, and trazodone for insomnia.
It is unlawful for primary care physicians to use another opioid to treat symptoms of withdrawal in the outpatient setting unless it is issued through a federally certified narcotic treatment program or prescribed by a qualified clinician registered with the US Drug Enforcement Administration to prescribe buprenorphine-naloxone.44
In some circumstances, it may be appropriate to abruptly discontinue opioids without a taper, such as when diversion is evident. However, a decision to discontinue opioids due to misuse should not equate to an automatic decision to terminate a patient from the practice. Instead, providers should use this opportunity to offer empathy and referral to drug treatment counseling and rehabilitation. A decision to discontinue opioids because they are no longer safe or effective does not mean that the patient’s pain is not real—it is “real” for them, even if caused by the pain of addiction—or that shared decision-making is no longer possible or appropriate.
Handling difficult conversations when discontinuing opioids
The conversation between patient and provider when discontinuing opioids can be difficult. Misaligned expectations of both parties, patient fear of uncontrolled pain, and provider concern about causing suffering are frequent contributing factors. Patients abusing prescription drugs may also have a stronger relationship with their medication than with their provider and may use manipulative strategies including overt hostility and threats to obtain a prescription. Providers need to maintain their composure to de-escalate these potentially upsetting confrontations.
Table 3 outlines some specific suggestions that may be helpful, including the following:
- Frame the discussion in terms of safety—opioids are being discontinued because the benefit no longer outweighs the risk
- Don’t debate your decision with the patient, but present your reasoning in a considered manner
- Focus on the appropriateness of the treatment and not on the patient’s character
- Avoid the use of labels (eg, “drug addict”)
- Emphasize your commitment to the patient’s well-being and an alternative treatment plan (ie, nonabandonment)
- Respond to emotional distress with empathy, but do not let that change your decision to discontinue opioids.
Finally, we strongly encourage providers to insist on being treated respectfully. When safety cannot be ensured, providers should remove themselves from the room until the patient can calm down or the provider can ask for assistance from colleagues.
Maintaining empathy by understanding grief
Discontinuing opioids may trigger in a patient an emotional response similar to grief. When considered in this framework, it may empower an otherwise frustrated provider to remain empathetic even in the midst of a difficult confrontation. Paralleling Kübler-Ross’s five stages of grief,45 we propose a similar model we call the “five stages of opioid loss”; this model has been successfully used in the residency continuity clinic at the University of Connecticut as a training aid.
Hopelessness and helplessness. During the first stage of the discussion the patient struggles with how to move forward. This conversation is frequently characterized by tearfulness and explanations to account for aberrant behavior or willingness to continue to suffer side effects. Active listening, empathy, and a focus on the factors that led to discontinuation of opioids while still validating pain are important.
Demanding and indignant. During the second stage, patients frequently push the limits of “no.” Accusations of abandonment and lack of empathy may accompany this stage and can be quite upsetting for the unprepared provider. A novice clinician can use role-play as a tool to better prepare for this type of encounter. Patients should be allowed to express their frustration but ultimatums and threats of violence should not be tolerated. Reassuring patients that their pain will be addressed using nonopioid therapy can be helpful, and a simple offer of continued care can help to preserve the therapeutic relationship.
Bargaining, the third stage of this model, is characterized by attempts to negotiate continued prescribing. While it can be frustrating, this push and pull is the beginning of real conversation and identification of a treatment plan for the future.
Resignation. The fourth stage begins when the patient has resigned himself or herself to your decision, but may not have accepted the available treatment options. At this point the patient may return for care or seek out a new provider. Empathy is again the element most crucial to success; this stage carries an opportunity to develop mutual respect.
Acceptance. The patients who choose to continue care with you have progressed to the final phase. They begin to look toward the future, having chosen the better of the two paths: partnering with a caring provider to develop a shared therapeutic plan.
A CONSISTENT AND TRANSPARENT APPROACH
Opioids can be useful for selected patients when they are carefully prescribed, but the prescriber must fully consider the risks and benefits specific to each patient and mitigate risk whenever possible.
Collaborating with patients to use opioids rationally is easier when it is part of a multimodal pain management plan and is initiated with clear functional goals and parameters for discontinuation. Presenting risks and benefits in a framework of safety and educating patients will help to reduce the stigma that may otherwise accompany safety monitoring using tools such as controlled substance agreements and urine toxicology testing.
Despite these efforts, patients may become psychologically dependent on opioids and discontinuation may prove difficult. However, a consistent and transparent approach to prescribing with special efforts to empathize with suffering patients may empower providers to navigate this process effectively.
