Is it time to taper that opioid? (And how best to do it)
This guide will help you to determine when to start an opioid taper and how to do so while maintaining pain control and minimizing the risk that the taper will fail.
PRACTICE RECOMMENDATIONS
› Continue opioid therapy only when it has brought clinically meaningful improvement in pain and function and when the benefits outweigh adverse events or risks. C
› Review the selected opioid tapering plan in detail with the patient and provide close follow-up monitoring of ongoing or emerging risks. C
› Be vigilant: Enacting an opioid-tapering plan can unmask opioid use disorder, which can cause the patient to seek alternative forms of opioids, including illicit, potentially lethal fentanyl analogues. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Use in pregnancy. Treatment with opioid medication in pregnancy warrants special consideration. In general, it’s wise to avoid opioid use in pregnant women because data on long- and short-term safety are limited.12 In 2015, the US Food and Drug Administration issued a safety announcement that further investigation is needed to determine whether the fetus is at increased risk of a neural tube defect related to opioid exposure during the first trimester.13 In women with an OUD, both methadone and buprenorphine are safe to use. Buprenorphine is associated with slightly better outcomes for neonatal abstinence syndrome and length of hospital stay.14
Ongoing monitoring of risk. Periodically assessing risk factors for opioid-related harm during continuation of opioid treatment is important. Tools such as the Opioid Risk Tool (ORT) or the Screener and Opioid Assessment for Patients with Pain-Revised, or SOAPP-R, can be used to evaluate the risk of misuse in adults who are prescribed opioids for chronic pain,15 although the evidence for utilizing these tools is inconclusive.11
Offering naloxone should be considered when factors that increase the risk of opioid overdose are present, such as a history of substance use disorder, a daily opioid dosage > 50 MME, concurrent use of benzodiazepines, and medical comorbidities that increase the risk of overdose (eg, sleep apnea, pulmonary disease, heart failure).16 Prescribers should review prescription drug monitoring program data, when available, to assess treatment adherence and to obtain a collateral history that might suggest abuse or diversion. Urine drug testing can be a useful adjunct to ongoing therapy—again, to assess treatment adherence and look for evidence of other substance use disorders.
Watchfulness for misuse and OUD. Opioid misuse—the nontherapeutic use of opioids—includes taking opioids in amounts other than prescribed, for indications other than prescribed, and administering by alternative routes other than prescribed (eg, crushing and snorting, rather than ingesting). The presence of opioid misuse does not always signify OUD. However, The Diagnostic and Statistical Manual of Mental Disorders, 5th ed.,17 defines OUD as out-of-control use; devoting increasing mental and physical resources to obtaining, using, and recovering from substances; and continued use despite adverse consequences.
Behaviors that increase the risk of, and might signal, opioid misuse and OUD include18
- seeking early refills
- obtaining opioids from the emergency room
- using medications prescribed to others
- using opioids to treat symptoms other than pain, such as anxiety or insomnia
- “doctor-shopping.”
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