Readdressing Opioid Dose Tapering and Buprenorphine Indications

tapering pills
tapering pills
Recognizing prescription opioid dependence and expanding the use of buprenorphine could improve the quality of life for patients with chronic pain.

Recognizing prescription opioid dependence and expanding the use of buprenorphine could improve the quality of life for patients with chronic pain and reduce fatalities, according to an article published in the Annals of Internal Medicine. The authors recommend establishing prescription opioid dependence as a distinct condition, and expanding buprenorphine indications to prescription opioid dependence.

The use of opioids to manage chronic pain has resulted in a population of patients on opioid therapy lasting for years or decades, many of whom have developed tolerance to the drugs and are taking doses above those set in the 2016 Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain. Intake of opioids at high doses places patients at risk for a range of adverse effects, including overdose. Extended opioid therapy has little benefit over nonopioid therapy and can negatively impact one’s quality of life, particularly in patients with opioid use disorder (OUD).

According to the authors, all patients on long-term opioid therapy should be assessed for opioid tapering based on their level of pain, functioning, and any adverse consequences, including addiction risk. Assessments should include information obtained from patients, clinicians, prescription monitoring data, and loved ones.

For patients in whom the benefit does not outweigh the harm, appropriate tapering strategies should be implemented. Because the CDC guideline for tapering opioids by 10% of the initial dose per week are based on studies on  addiction treatment, new guidelines are needed based on recent data that indicate that patients with chronic pain may benefit from smaller reductions over a much longer time period (ie, years). The speed of the taper should depend on individual patient response, with supportive therapies and incentives to ensure progress, quality of life, and improved functioning.

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A key aspect of this process will be recognizing prescription opioid dependence as a distinct clinical condition. Even with stable opioid doses, subthreshold withdrawal between doses is possible, and tapering may exacerbate symptoms like hyperalgesia and dysphoria. Some patients may not meet the Diagnostic and Statistical Manual of Mental Disorders 5criteria for OUD but experience withdrawal symptoms and have difficulty tapering. Recognizing dependence as a condition should contribute to reducing stigma associated with the condition, and allow for the use of management interventions that will lower the risk for morbidity, including the potential for escalating to an OUD diagnosis.

Recognition of prescription opioid dependence as a distinct condition would also allow for buprenorphine indications to be expanded to this patient population. Buprenorphine can assist tapering with a lower associated risk compared with pure opioid agonists.

“Recognizing prescription opioid dependence as a potential comorbid condition and expanding use buprenorphine could save lives, improve quality of life, and reduce incidence of nonlethal unintentional overdose,” conclude the article’s authors.

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Chou R, Ballantyne J, Lembke A. Rethinking opioid dose tapering, prescription opioid dependence, and indications for buprenorphine [published online August 27, 2019]. Ann Intern Med. doi: 10.7326/M19-1488