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
Although withdrawal is generally not considered life-threatening in patients without significant comorbidities, do not underestimate the severity of withdrawal symptoms. Often, the desire to avoid these intense symptoms drives patients with OUD to continue to overuse.
Increased pain. Patients might fear that pain will become worse if opioids are tapered. Although it is important to acknowledge this fear, studies of patients undergoing a long-term opioid taper report improvements in function without loss of adequate pain control; some even report that pain control improves.32
Three long-term risks
Relapse. The most dangerous risk of tapering opioids is use of illicit opioids, a danger made worse by the increasing presence of highly lethal synthetic fentanyl analogues in the community. Risk factors for relapse following a full taper include the presence of depressive symptoms at initiation of tapering and higher pain scores at initiation and conclusion of the taper.33 Having low pain at the end of an opioid taper, on the other hand, is predictive of long-term abstinence from opioids.32
Declining function. As is the case while prescribing opioids for pain, maintenance of function remains a priority when tapering opioids. Function can be difficult to assess, given the many variables that can influence an individual’s function. Psychosocial factors, such as coping strategies and mood, strongly influence function; so do psychiatric morbidities, which are more prevalent in patients with chronic pain and disability, compared with the general population.34
Medicolegal matters. Although difficult to characterize, medicolegal risk is an inevitable consideration when tapering opioids:
- In a study of closed malpractice claims involving all medical specialties, narcotic pain medications were the most common drug class involved, representing 1% of claims.35
- In a study of closed malpractice claims involving pain medicine specialists, 3% were related to medication management. Most claims arose following death from opioid overdose.36
Continue to: What else is needed in this area of practice?
