ESTES PARK, COLO. – Now that the opioid epidemic has formally been declared a national emergency, physicians can expect to encounter growing pressure to taper opioids in their chronic pain patients, Sunny Linnebur, PharmD, predicted at a conference on internal medicine sponsored by the University of Colorado.
As an example of what physicians around the country might expect, she added, Colorado state health officials recently announced that coverage of opioid therapy for Medicaid patients will be reduced. State health officials recommended that physicians taper down their patients’ opioids.
Fortunately, helpful tools for doing so are just a few mouse clicks away, according to Dr. Linnebur, professor of clinical pharmacy at the University of Colorado, Aurora.
Indications for opioid tapering as described in a guide provided by the Centers for Disease Control and Prevention include lack of a sustained or clinically meaningful improvement in pain and functioning as defined, for example, by at least a 30% improvement on the three-item PEG scale; use of opioids at a daily dosage of 50 morphine equivalent doses or more without evidence of benefit; signs of a substance use disorder other than tobacco dependence; warning signs of harms, such as drowsiness, slurred speech, or difficulty controlling use of the medication; patient request; and any situation where the physician deems that the benefits no longer outweigh the risks (www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf).
General principles of tapering opioids as outlined by the CDC include reducing the dosage by about 10% a week at a time – although if a patient has been on opioids for years, then at a slower rate, perhaps 10% per month, may be more appropriate. If a patient has been using a 12.5 mcg/hour fentanyl patch, a switch to an oral opioid is recommended to complete the taper. When the smallest dosage has been reached, the interval between doses can be stretched; and once the medication is being taken less than once per day, it can be stopped.
Bruce Jancin/Frontline Medical News
Dr. Sunny Linnebur
Of course, discontinuation often is not possible. Patients generally tolerate weaning to 30%-50% of their original dose, Dr. Linnebur continued.
She highlighted an opioid tapering schedule form developed by experts at the Washington State Health Care Authority as being particularly useful.
“If you type in a patient’s opioid medication and dose, it will give you a week-to-week calendar schedule for tapering,” she explained. “We know that getting patients on the safest dose of opioid is important, but it’s also difficult. This is an objective taper schedule that will prevent the patient from withdrawing from their opioid and hopefully will help in tolerating the reduction.”
Dr. Linnebur reported having no financial conflicts of interest regarding her presentation.