Tips and tools for safe opioid prescribing
This review—with tables summarizing opioid options, dosing considerations, and recommendations for tapering—will help you provide rigorous Tx for noncancer pain while ensuring patient safety.
PRACTICE RECOMMENDATIONS
› Use a screening instrument such as the Opioid Risk Tool or the DIRE assessment to gauge a patient’s risk of opioid misuse and determine the frequency of monitoring. C
› Give as much priority to improving functional activity and minimizing adverse opioid effects as you do to relieving pain. C
› Prescribe an immediate-release, short-acting agent at first instead of a long-acting formulation; start with the lowest effective dosage and calculate total daily dose in terms of morphine milligram equivalents (MME). C
› Reduce the original MME dose by 5% to 10% every week when discontinuing an opioid. 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
When working with a patient to taper treatment, consider using a multidisciplinary approach. Also, assess the patient’s pain level and perception of needs for opioids, make clear the substantial effort that will be asked of the patient, and agree on coping strategies the patient can use to manage the taper.31,43 While the evidence does not appear to support one tapering regimen over another, we can offer some recommendations on ways to individualize a tapering regimen (TABLE 5).1,31,41,43,44
General recommendations. Gradually reduce the original MME dose by 5% to 10% every week to every 4 weeks, with frequent follow-up and adjustments as needed based on the individual’s response.1,31,41,43 In the event that the patient does not tolerate this dose-reduction schedule, tapering can be slowed further.31 Avoid abrupt discontinuation.33 Opioid abstinence syndrome, a myriad of symptoms caused by deprivation of opioids in physiologically dependent individuals, although rare, can occur during tapering and can be managed with clonidine 0.1 to 0.2 mg orally every 6 hours or transdermal clonidine patch 0.1 mg/24 hours weekly during the taper.31
Tapering of long-term opioid treatment is not without risk. Immediate risks include withdrawal syndrome, hyperalgesia, and dropout, while ongoing issues are potential relapse, problems in increasing and maintaining function, and medicolegal implications.43 Withdrawal symptoms begin 2 to 3 half-lives after the last dose of opioid, and resolution varies depending on the duration of use, the most recent dose, and speed of tapering.43 In general, a patient needs 20% to 25% of the previous day’s dose to prevent withdrawal symptoms.31 Increased pain appears to be a brief, time-limited occurance.43 Dropout and relapse tend to be attributed to patient factors such as depressive symptoms and higher pain scores at initiation of the taper.43 Low pain at the end of tapering has been shown to predict long-term abstinence from opioids.43
CASE
Two months into his oxycodone regimen, Mr. G reported improved functional status at his catering job and overall improved quality of life. He had improved his lifting form and was attending biweekly physical therapy sessions. His pain score was 3/10. He expressed a desire to “not get hooked on opioids,” and mentioned he had “tried stopping the medicine last week” but experienced withdrawal symptoms. We discussed and prescribed the following 5-week taper plan: 2.5 mg reduction of oxycodone per dose, every 2 weeks x 2. Then 2.5 mg PO every 6 hours as needed x 1 week before stopping.
Organizing your approach
To optimize the chance for success in opioid treatment and to heighten vigilance and minimize harm to patients, we believe an organized approach is key (TABLE 614,22-24,28,30-32), particularly since this class of medication lacks strong evidence to support its long-term use.
CORRESPONDENCE
Tracy Mahvan, PharmD, BCGP, University of Wyoming, School of Pharmacy, 1000 East University Avenue, Laramie, WY 82071; tbaher@uwyo.edu.
