The American Academy of Pain Medicine (AAPM) Foundation, as part of a consensus panel project, has developed new recommendations for tapering opioids in patients with chronic pain. The recommendations were published online in Mayo Clinic Proceedings.
Formation of the Guideline
The AAPM Foundation convened a group of interdisciplinary pain experts and a patient advocacy representative in Chicago, Illinois, on April 2019. The panel reviewed the literature and discussed clinical experience to identify and discuss key questions regarding the timing, ethics, and methods for reducing opioid consumption in chronic pain.
Recommendations on Opioid Tapering Indications
Clinicians should reduce opioid doses unless the opioid has demonstrated benefit and alternative analgesic options are either not beneficial or feasible. Opioid medications with benzodiazepines should be reduced or the benzodiazepine itself should be reduced or discontinued, unless the combination approach has shown benefit and there are no other available beneficial or feasible alternatives.
Patients should be made aware that high dose opioids, if continued, exceed the current recommendations and are “associated with higher than usual risk,” according to the panel. This awareness should be documented by the clinician.
Reducing Medical Complications During Tapering
For patients in serious danger of medical complications or overdose, the panel recommends that clinicians initiate opioid tapering strategies. While several studies suggest tapering offers benefit without harming the patient, other studies suggest consensual dose reductions may be associated with worsening of pain. Involuntary opioid discontinuation may be associated with a higher overdose risk, emergent hospital or emergency department utilization, termination of care, and suicidal behavior.
The panel noted that patients who agree to taper will often tolerate the taper better than patients who do not agree. For patients who are opposed to taper and are depressed, the consensus is that the depression should be treated prior to the taper. Additionally, the interdisciplinary panel recommends that patients should receive a considerable amount of education, time, and counseling before and during opioid tapering process.
The panel also suggests that withdrawal distress in patients who ultimately discontinue opioids should be planned for and subsequently treated with adjuvant agents. Pharmacologic adjuvants to opioid reduction such as α-2 agonists can attenuate opioid withdrawal. Clonidine may suppress withdrawal symptoms, but this medication may also increase the risk of orthostasis or hypotension in some patients.
Buprenorphine is another potential option that is sometimes used off-label for chronic pain. It is currently approved to treat opioid use disorder (OUD) when combined with naloxone. While the use of buprenorphine/naloxone for OUD requires a Drug Enforcement Agency waiver, there are no current federal restrictions when it is used off-label for analgesia. The panel stated a trial of buprenorphine/naloxone may be warranted when neither opioid dose escalation nor reduction is possible, noting that the combination has abuse-deterrent properties.
Recommendations for Initiating the Taper
When starting the taper, the panel recommends that an opioid taper agreement or informed consent be discussed and signed by the patient and their treating clinician. Depression, anxiety, and insomnia should also be addressed prior to and during the tapering process.
Additionally, clinicians should conduct an addiction assessment prior to tapering, particularly in patients with a history of OUD. The panel also recommended that clinicians make buprenorphine available with or without naloxone, in all delivery systems and dosages, for pain management. The endorsement for buprenorphine use for the treatment of pain did not necessitate a diagnosis of OUD.
The rate of the taper should be determined by the patient’s ability to tolerate it. Very small dose reductions should be implemented initially to help increase the patient’s confidence in the process.
Avoiding Disruptions in Patient Care
The panel discouraged major opioid dose reductions and “cold referrals” to other clinicians who had not previously agreed to accept care for a patient. A safe opioid tapering regimen, agreement from another clinician to oversee care, or replacement of mu-opioid agonists with buprenorphine should always be made available to patients receiving long-term opioid therapy.
Psychosocial Treatment Recommendations for Opioid Reduction
Only a small number of studies have examined the role of psychosocial treatments for reducing opioids. Physical exercise and fitness training may help with opioid withdrawal and reduce chronic pain, but the data to support a recommendation for these approaches are sparse.
The panel recommends that patients undergoing opioid tapering strategies should receive behavioral therapy support. The goal of these therapies is to primarily reduce withdrawal-related anxiety and increase retention.
Limitations of the Recommendations
The expert panel clearly outline in their consensus statement that the evidence on which the recommendations are based is “suboptimal,” as very few randomized studies on opioid reduction or discontinuation have been performed.
In spite of this limitation, the panel wrote that it believes the available data support the recommendations made, but additional research is needed to further support or refute the panel’s conclusions.
The AAFM panel concluded that it depends on “payers, suppliers, and regulators to recognize and support flexibility in long-term opioid treatment dosage and duration” and “to promote access to nonopioid treatments for chronic pain and to incentivize their provision.”
The panel added that the current data “highlight the importance of assessing the whole person when considering opioid reduction or discontinuation.”
Disclosure: This clinical trial was supported by Collegium Pharmaceutical, Orexo, and US WorldMeds. Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Covington EC, Argoff CE, Ballantyne JC, et al. Ensuring patient protections when tapering opioids: Consensus panel recommendations. Mayo Clin Proc. 2020;95(10):2155-2171. doi:10.1016/j.mayocp.2020.04.025