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
Furthermore, psychiatric comorbidities,19 a personal or family history of substance use disorder,20 and a preadolescent history of sexual abuse21 are associated with a higher risk of a substance use disorder.
If OUD is identified, remain nonjudgmental and acknowledge that addiction is a chronic disease. Assumptions about a patient’s character or morality have no place in the appropriate management of OUD; remain mindful of your own implicit biases.
When is it appropriateto start an opioid taper?
The decision to taper opioids is difficult and can provoke anxiety for both prescriber and patient. Complicating matters is that there is insufficient evidence to evaluate opioid dosage-reduction interventions for patients with chronic noncancer pain.22
Safety concerns. Even in patients who are taking opioids as prescribed and for whom no red flags have been raised, the long-term safety of high-dosage opioids remains unclear. There is no “safe” dosage of opioids; however, evidence is clear that the risk of death from overdose increases with dosage. Compared with patients taking a dosage anywhere from 1 to 20 MME/d, those taking 50 to 99 MME/d have a 3.7-fold increased risk of overdose; patients taking ≥ 100 MME/d had an 8.9-fold increased risk.23 Patients for whom concomitant benzodiazepines are prescribed are also at higher risk of overdose and death. In studies of opioid overdose deaths, there was evidence of concurrent benzodiazepine use in 31% to 61% of cases.11
Inadequate analgesia. Given the well-established risk of drug tolerance, the inability to achieve or maintain pain relief or functional improvement can still occur—even when the opioid dosage is escalated reasonably. It might be prudent in that situation to taper opioids while also considering alternative modalities, including ones that were deferred previously.
Continue to: Intolerable adverse effects
