Don’t Fear Opioid Tapering

LAS VEGAS — As the outcry against opioid use and abuse continues to increase in intensity, more  prescribers are becoming increasingly reluctant to write a prescription for opioid analgesics for their patients with pain symptoms. With the opioid abuse epidemic now featuring prominently in news media, patients are becoming more knowledgeable on the topic and some will look to their physician to provide an alternative treatment for their chronic or acute pain. However, weaning patients off opiates can be a challenging task for any medical professional.

“Opioid tapering is always met with dread and anxiety, both by patients and by providers,” said Lee A. Kral, PharmD, BCPS, CPE, Clinical  Pharmacy Specialist and Adjunct Assistant Professor in the Department of Anesthesia at the University of Iowa Hospitals & Clinics, Center for Pain Medicine, in Iowa City, Iowa.

She and her colleague, Tanya J. Uritsky, PharmD, BCPS, Clinical Pharmacy Specialist in Pain and Palliative Care at the Hospital of the University of Pennsylvania, in Bryn Mawr, Pennsylvania, at PAINWeek 2015 reviewed how prescribers can successfully wean patients off of prescription painkillers.

According to the presenters, there are a number of reasons why a prescriber may want a patient to undergo opioid tapering: lack of efficacy, the therapy is no longer needed, unacceptable risk, behavioral concerns, or surgical risk.

“As a society, we need to be ready to make adjustments,” Kral said. “Many patients are started on opioids because providers don’t know what else to use. When it is decided that the opioid really isn’t offering much benefit, or has adverse effects, nobody knows what to do.”

Opioid tapering may begin with discharge prescriptions, when physicians indicate that the typical length of therapy has been reached, or if a patient would like to proceed with tapering earlier. Patients receiving chronic opioid therapy before surgery are likely to need postoperative supplemental medication for a longer duration of time.

“We need to be in a place to appropriately taper (either decreasing the dose or tapering off) opioids without fear and anxiety,” Dr. Kral noted. “This can be done in a rational, thoughtful way that does not jeopardize patient safety and should not cause a lot of drama for anyone.”

Having patients use their own medication to taper off works best if the patients can tolerate the weaning. Long-acting agents are preferred, and they should be dosed at regular intervals. Short-acting agents are not recommended, except in the setting of acute pain. If a patient has a history of substance abuse, clinicians are advised to switch the patient to morphine.

The duo told the audience that there is no standard speed for opioid tapering, and the rate of weaning should be determined based on the individual patient. Abrupt stopping can be considered for patients taking short-term, short-acting opioids. Weaning should be implemented for opioid-tolerant patients.

Opioid-tolerant patients are those who have been taking any of the following medications for at least one week: morphine, 60 mg/d; transdermal fentanyl, 25 mcg/h; oral oxycodone, 30 mg/d; oral hydromorphone 8 mg/d; or oral oxymorphone, 25 mg/d. Clinicians should also consider the presence of certain, such as underlying cardiorespiratory disease and comorbid psychiatric diagnoses, when determining the speed of taper. In addition, patients may request a slower taper to avoid withdrawal.

“The best way to taper an opioid is as slow or as fast as the patient tolerates it, without causing harm or withdrawal,” Dr. Kral said. “Every opioid and every patient is different and tapering must be individualized.”

Adjustment of the medication schedules and dosing during tapering is an option if patients are feeling anxious and fearful about tapering; if pain is recurring or worsening; or if patients are experiencing withdrawal symptoms.

Dr. Kral reported that she wants to see her peers become “more comfortable with starting, maintaining and adjusting tapering regimens to prevent withdrawal and achieve good outcomes.”

Easing the patient into the tapering process by preparing them psychologically, as well as providing individualized care and supportive measures are key to successful outcomes.