Roles and Issues in Advance Practice Nursing

A Patient-Centered Approach to Opioid Tapering Transcript

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Hi, this is Dr. Daniel Alford from Boston University's School of Medicine and Boston Medical Center.

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I'm going to be speaking to you today about a patient-centered approach to opioid tapering.

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Our outline includes first talking about some important definitions, then went to consider an opioid taper, discussing taper with patients, talking about legal and language considerations, talking specifically about withdrawal and management of withdrawal, and then getting into some tapering regimens.

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Let's start with important definitions.

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When patients are taking opioids, we need to understand the difference between tolerance and physical dependence. Both tolerance and physical dependence are physiologic are physiologic adaptations to being chronically on opioids. Remember that tolerance means that you require an increased dose to produce a specific effect. We know that tolerance develops readily for CNS and respiratory depression, less so for constipation, and in terms of tolerance to analgesia it is a bit controversial in terms of whether or not it exists but it seems to, for some patients and not others. Physical dependence includes the signs and symptoms of withdrawal with abrupt opioid discontinuation or cessation, rapid opioid dose reduction or the administration of an opioid antagonist resulting in withdrawal symptoms.

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Now let's talk about opioid use disorder, based on the DSM V criteria. You will see that there are a list of symptoms here including tolerance and withdrawal. Now since moving from the DSM IV to DSM V there was an appreciation that if patients are prescribed opioids for pain that they will have tolerance and withdrawal; that is, physical dependence, so those should not be considered part of the diagnosis of an opioid use disorder if the patient is taking an opioid as prescribed, but when you look at some of the other symptoms such as used in larger amounts or duration than intended, a persistent desire to cut down, giving up other interests to use opioids, a great deal of time spent obtaining using and recovering from other opioids and other symptoms you will see that some of these may be related to pain and not necessarily an opioid use disorder. That is, there certainly some patients who are on opioids for longer amounts of time than intended but every time they come off their opioids the pain gets worse, or they have this persistent desire to come off the opioids, but again when they try to do so their pain gets worse. Some patients spend a lot of time trying to find someone willing to prescribe an opioid for their pain, so although these are the criteria for an opioid use disorder it can sometimes be tricky in patients who are on opioids for chronic pain. The other thing to note is that the DSM V categorizes a mild opioid use disorder in individuals that have 2-3 criteria, a moderate disorder in people with 4-5 primary and a severe opioid use disorder in individuals that have greater than or equal to 6 criteria.

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The next term is addiction, and addiction is not a DSM V diagnosis, but it is a term that many people use in describing a certain syndrome as it relates to an opioid use disorder. By DSM V we are really talking about a moderate to severe opiate use disorder, but the clinical syndrome presents as loss of control. The patient cannot take the medication or the opioid as prescribed. They keep running out early or showing up in the emergency room. Compulsive use is a preoccupation with the opioid; that is, everything else that you recommend for the pain management, they don't want to hear about it. All they want is more opioid. Continued use despite harm is someone who is having negative consequences from the opioid like falling asleep in the middle of the day or slurring their words or falling, and as opposed to what you would expect; that is, they would want less, they actually want more of the opioid. In some individuals we will talk about this continuous urge to take the opioid, and that would be called craving. All of these behaviors are referred to as aberrant medication taking behaviors. We are worried about not only the pattern but the severity as well. It only takes one time for me to get call from the pharmacy that someone has altered the prescription in some way, and that would be severe enough that I would say their behavior is consistent with an opioid addiction. But really in summary here I think the important take away message is that addiction is a behavioral maladaptation to being on opioid are being exposed to an opioid whereas physical dependence is a physiologic adaptation to being exposed to an opioid and is not the same as addiction.

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All right, so now let's talk about when to consider an opioid taper.

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Certainly you would want to consider it if somebody is not adequately progressing towards their treatment goals, and this really relies on you having specific treatment goals agreed upon with the patient early on in the treatment plan. Those goals should be specific and measurable so that you can follow them over time. But also you will consider a taper if the person has declining level of function, where their pain is just increasing over time which may be consistent with opioid induced hyperalgesia or this paradox or response that some patients on chronic opioid therapy the pain actually gets worse. There may also be the patient who has a persistent nonadherence with their treatment plan. There may be side effects or risks that outweigh the benefits of the opioid therapy. There may be some risky behaviors that are indicative or suggestive of opioid misuse; that is, the person is taking them in a way that is not prescribed and it would just be unsafe to continue to prescribe the opioid. You may have concerns that the person may be diverting, giving away, or selling their opioid or that they have developed an opioid use disorder or an addiction. There may be patients who are concerned about being on opioids such as the stigma, the cost associated with it or the physical dependence that is associated with them. And then finally some patients on long-term opioids who are stable and there are no worrisome behaviors, it may be worth a periodic trial of a taper just to assess whether or not they still need the opioid for the pain or not.

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Now let's talk about how to discuss taper with your patients.

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The first thing is to be clear in your own mind why you think the taper is indicated. Is it because of a lack of benefit or is it because you are worried about the person's behaviors; that is, a loss of control, compulsive use, or continued use despite harm? Center the discussion on health concerns. This is not about whether the patient is good or bad or whether you trust this patient. It is really about is this patient's health improving on this treatment or is it getting worse? Aim for the patients who understand and agree with your rationale.

Now oftentimes patients will disagree with the plan for a taper, and why might that be? Well, it might be that they are fearful their pain is just going to become more severe or that they are going to go through opioid withdrawal and be uncomfortable or that some other symptom, maybe depression or anxiety, will get worse off the opioid. Maybe they have psychological dependence on the opioid; that is, in their mind the only thing that has ever worked for them or ever helped their pain is an opioid and they feel very attached to it. But they may also have an open use disorder or addiction. Again, if you suspect that they have an opioid use disorder or addiction based on loss of control, compulsive use, or continued use despite harm make sure you refer them to a specialist, an addiction psychiatrist or an addiction medicine specialist, because tapering somebody with an opioid use disorder without referring them to addiction treatment can increase the risk of adverse effects, certainly someone could be at risk for overdose if they start to use drugs illicitly and so forth.

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Clearly state the reasons for the taper, and here are some examples of language you could use. For example, "I believe it is unsafe for you to continue this opioid because…" you were unable to make control of the use of the opioid or you take more than has been prescribed over time, so be specific in your examples as to why you think it is unsafe. You may say "I believe the opioids may be increasing your pain." Again, this is the whole concept of opioid induced hyperalgesia. "We are not achieving the goals that we agreed upon, that we targeted, and although we had hoped that the opioids would help they clearly have not based on my observations over time." What you want to avoid is language like "well, the guidelines won't let me prescribed," because that is not actually true, or "I'm not allowed to prescribe these doses because of the DEA or of the FDA," and it is also not true, either, although some states may have enacted laws or regulations that prohibit certain medications or certain doses, so you need to be aware of those.

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Now when you're discussing the taper, remind the patient that you believe their pain is real, that you believe their self-reports of how severe the pain is in their suffering, and make it clear that you are not abandoning the patient, but you are abandoning an ineffective and/or harmful treatment, in this case opioids. Empower the patient with tapering options when possible, so it may be that your taper is going to be over months and you can ask the patient to help set the timeline or schedules for taper, and that improves their sense of self-efficacy. How much are they able to and willing to taper over the next month or the next two months? Offer continued care but not continued opioids. Discuss and implement alternative pain management strategies and make sure you are treating other symptoms that may be exacerbated by being off opioids. Work towards a foundation of self-management; that is, the patient should not be 100% reliant upon you to make the pain better, but they need to do something around self-care, pacing their activities during the day, avoiding certain activities that may exacerbate the pain to improve their own self-management, and then include other targeted treatments as indicated.

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Remember that we have a whole toolkit of various treatments to help our patients with chronic pain that are both clinical care and self-care, and that our goals are not just to reduce pain but to restore function, to improve quality of life, and to really cultivate well-being, and some of the options include psycho behavioral treatments, cognitive behavioral therapy, meditation, relaxation, procedural treatments including nerve blocks and steroid injections, physical therapy such as exercise, orthotics, acupuncture, and then medications and it is obviously not just opioids. There are nonsteroidal anti-inflammatory drugs, acetaminophen, anticonvulsants, antidepressants and so forth.

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So now let's talk about legal and language considerations.

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What we are really talking about here is termed tapering or weaning. What we are not talking about is detoxification, which is really reserved for withdrawal from intoxicating drugs or medications in the context of addressing addiction, and this really requires appropriate waivers or affiliations.

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To detox or detoxify a patient due to an opioid addiction, using an opioid medication, the provider must have a DEA waiver to prescribe buprenorphine for an opioid use disorder treatment or must be affiliated with a licensed opioid treatment program; for example, a methadone maintenance treatment program, which is state and federally licensed. To withdraw patient from opioids prescribed for pain, including individuals who have a co-occurring addiction, you don't need a special DEA waiver and you don't need to be affiliated with a methadone maintenance treatment program and you really could use any opioid analgesic for that opioid analgesic taper.

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There are some exceptions to the DEA waiver or license requirements around tapering. For example, a patient who is admitted to a general hospital for a diagnosis other than addiction, maybe it's a medical diagnosis or surgical diagnosis, opioid withdrawal can be treated throughout the admission with any opioid including methadone or buprenorphine. You don't need a DEA waiver, so an opioid including methadone or buprenorphine can be taper during that inpatient stay if the primary diagnosis for why that patient is in the hospital remains other than addiction. You cannot continue the opioid taper for addiction as an outpatient unless you are wavered to prescribe buprenorphine for an opioid use disorder or affiliated with a licensed methadone treatment program. Any DEA register prescriber may administer not dispense or prescribe opioids to prevent withdrawal for three days while arranging for treatment for a patient with an opioid use disorder. Let me explain that. So if an individual has an opioid use disorder and you are trying to get them into specialty treatment, you can arrange for an opioid to be administered for observed ingestion for three days while you are trying to get them into addiction treatment, so you cannot write a prescription for a three-day supply. You can't dispense a three-day supply; that is, give them three days of doses of opioids, but you can observe them for three days taking a dose, and usually that would be in an emergency room setting.

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Now let's talk about withdrawal and management.

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Acute opioid withdrawal, the onset is 2 to 5 half-lives with some variability after the last dose of the opioid if the person is physiologically dependent, so someone who is taking an opioid that is short acting, occasionally, likely doesn't have physical dependence, but someone who is taking an opioid around-the-clock on a daily basis likely does have physical dependence. Now the duration of withdrawal will be longer, the longer the opioid half-life, so an individual on an extended release opioid is going to have a longer duration of withdrawal. Someone who is on a short acting immediate release opioid is going to have a shorter duration. The common symptoms include CNS arousal (that is irritability residences, sleeplessness and pacing) and also autonomic arousal, you know sweating, yawning, runny eyes, runny nose, diarrhea, tachycardia, and hypertension. In the going to have pain. Whatever pain they have will be worse and they are going to have muscle aches and bone aches and joint pain in stomach cramping and so forth. It can be extremely uncomfortable, and rarely though is a life-threatening, although individuals who have gone through opioid withdrawal say that they may not die from it but they would rather be dead because the symptoms are so severe.

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So how do we manage withdrawal? Well the taper, if it is gradual, we usually avoid severe acute withdrawal. If an abrupt cessation is necessary, or if withdrawal symptoms are occurring, we need to reassure the patient that these are painful symptoms but will not be long-term harmful. We need to make sure the patient stay hydrated, and we can do symptomatic treatment is indicated, so for the generalized sympathetic arousal you can use an adrenergic agonist like clonidine or tizanidine to treat withdrawal symptoms. Certainly, joint and muscle pain can be treated with nonsteroidal anti-inflammatory drugs. The diarrhea and cramping you can use low pair of miter antispasmodics. Insomnia can be treated with trazodone or an antihistamine. Anxiety or sleep certainly you could use a short-term benzodiazepine with extreme caution and nausea and vomiting symptoms can also be managed.

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It is important to remember that there is also, beyond acute opioid withdrawal, a chronic or post acute withdrawal syndrome or called protracted withdrawal, and this is a syndrome that can persist for weeks to months. Common complaints include sleep disturbance, fatigue, anhedonia, irritability, increased pain sensitivity, patients need to be aware that it is possible and can last weeks to months but it is self-limited.

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What about reemergence of symptoms? So underlying symptoms that have been attenuated by opioids may reemerge during the taper, and we need to distinguish whether or not those symptoms are due to withdrawal, which are going to be time-limited, or whether or not they are going to be chronic. We need to think about alternative approaches to treating those symptoms if they are going to be chronic and persistent. Some of these are going to be short-term symptoms and some will be longer-term including worsening pain, anxiety, depression, and sleep disturbance.

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Now let's talk about tapering regimens.

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The goals during taper are we would like to avoid or minimize withdrawal and/or rebound pain. We want to maintain patient safety, but we need to work within our system constraints. The first thing to consider is what is the expected degree of physical dependence? How long has the person been on opioids? Are they taking them around-the-clock? Or is it intermittent use and there is unlikely any physical dependence and therefore you wouldn't need to taper. What are the patient's preferences and goals? And the reason for the taper? If it is misuse and risk, the taper is going to be much more quick than if it is lack of benefit.

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So what are the options? So immediate discontinuation; that is, no taper-will certainly if the person is diverting and doesn't have physical dependence you don't need to taper. You would be concerned about diversion if the person's urine drug test was negative for the medication you're prescribing or if they were not adhering with pill counts. You would also do an immediate discontinuation without a taper if the person was high risk; that is, high risk for an overdose or high risk for a substance use disorder or they are unable to follow the taper schedule in a safe way. These are people who will likely need referral to specialty addiction treatment to be tapered off their opioid. You may decide that the taper needs to be rapid using a highly structured taper over 2-4 weeks and this would be someone who is Iris but someone was able to follow the tapering schedule in a safe way, or you might decide that the taper can be slow; that is, over weeks to months and that is someone who has lack of benefit and no risk and there are no acute safety concerns.

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It is important to appreciate that there are no validated tapering protocols or published comparisons of speed of taper in patients on long-term opioids for chronic pain. But there is a general approach, which really is more of an art than a science. Again, the speed of taper depends on your level of concern. If it is lack of benefit you can do it over weeks to months, but if it is apparent on more risk you are talking about these two weeks. The first thing you're going to do is reduce the medication dose to the smallest available dosage unit, then when you get to the smallest dose you can increase the amount of time between doses, and you might end up switching from an extended release long-acting opioid to a short-acting opioid to get to lower and lower doses. Remember that you can use an alpha adrenergic agonist like clonidine or tizanidine that would be off label use for both of those medications to treat withdrawal symptoms. Make sure you are building up alternative pain treatment modalities as short-term withdrawal from the opioid can lead to transitory increased pain.

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Now there are many ways to taper, and here are some examples for starting points to follow.

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For a relatively rapid taper; that is, over 2 to 4 weeks you may taper 20% of the original dose every 2-4 days. Then at 20-30% of the original dose, recalibrate to a smaller decremental decrease. Consider a second recalibration at the very end. This is an example of someone who has tapered over 22-26 days off of high-dose morphine.

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A slower taper example over 3-4 months would be to taper 10% of the total dose per week to start and then recalibrate to smaller decrements once you're at about 20%-30% of the original dose. Consider a second recalibration at the very end, and here again we give you an example of how you might do that.

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Now let's talk about what are the endpoints of your taper? A complete taper is your endpoint only if you are worried about the risks of major opioid associated harm. Other tapirs are really trials, and it is not a failure if you don't taper the person completely off opioids if the elective trial of a taper off opioids increases the person's pain and they are unable to tolerate it or maybe you have completed the taper and the patient states that their pain is worse than it was while they were on opioids and therefore it might be indicated to restart the opioid at a lower dose. Sometimes I will ask the patient when they have been tapered off the opioid, "Is your pain better, worse, or the same?" Clearly, if it is better or the same then we have made some progress because they are no longer on opioid and their pain is either better or unchanged, but if their pain is worse that may be an indication to restart the opioid at a lower dose, but again the endpoint of the taper is not always to get the person completely off of the opioid. However, keep in mind that side effects and analgesia may improve in some patients at a lower opioid dose. If so, that may be the appropriate endpoint; that is, a lower opioid dose rather than being completely off the opioid.

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Now let's talk about two tapering case scenarios just to apply what we have talked about.

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The questions in considering and opioid taper include is the patient safe? If not, how can we ensure safety? What are the indications for taper of the opioids in the first place? How can we avoid acute withdrawal symptoms or treat them if necessary? What alternatives are available to address pain including engagement in self-management or self-care and active treatments to address the pain other than opioids? What other underlying symptoms may need to be addressed? Are there additional expertise or partners needed for optimum care?

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Our first case is a 55-year-old male with a history of multiple back surgeries, and he is taking extended release long-acting oxycodone 60 mg twice a day, with short-acting oxycodone 5 mg up to three times a day for breakthrough pain. The patient feels that the plan is working well. He never asks for early refills there has been no worrisome behaviors, and he has been on this regimen for the past 10 years since his last back surgery. The question is, does he need a taper? Clearly he is on high-dose opiates for a long period of time, and I would recommend to this patient a trial of a taper; that is, to at least try to get a lower opioid dose. It might be that he doesn't require this level of opioid therapy as his back may have healed over the years. We will know that unless we try to taper him to a lower dose. Now this is going to take some time to convince the patient that a lower dose may do just as well is a higher dose, so that is something that we will discuss over time. Again, my rationale is does he really need to be on such high dosages over such a long period of time? The answer may be yes, but we don't know unless we have tried tapering him to a lower dose. How would I taper? I would taper over months, maybe even years. Again, the goal here, the endgame here, is to try to continue to achieve the same benefits but maybe with a lower dose opioid. I'm also going to talk to him about alternative therapies, maybe acupuncture and maybe cognitive behavioral therapy, maybe even physical therapy. These are therapies that he may have tried in the past but they may be worth trying again, and really focusing on multimodal care. Maybe he can tolerate having low-dose acetaminophen or a nonsteroidal anti-inflammatory drug to help with synergy along with the oxycodone.

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What about a 39-year-old female with hip, knee, and back pain? She was initially started on opioids 5 years ago after a motor vehicle crash. She would do well for 4 to 6 months and then would request the dose increase, and then over the past 5 years due to this escalation in doses she is now on extended release long-acting morphine 30 mg three times a day and oxycodone 5 mg four times a day p.r.n. for breakthrough pain. She frequently calls several days to a week early for refills and today she is asking for an increase in her dose. Does she need a taper? Well, I certainly get the sense that she is not benefiting and that there is either tolerance or opioid induced hyperalgesia causing this worsening pain requiring higher and higher doses, and I would really be reluctant to give her a higher dose, and I'm really going to pay close attention to adverse effects and any negative consequences from her opioid use, and is she achieving functional goals? Is she working? Is she able to function on these medications? But the answer is, you know, if she is not benefiting or if I suspect that there is some risk, then I would say a taper is absolutely indicated, and my rationale again would be based on whether or not I think it is likely to benefit and/or risk or harm. Again, my taper is going to depend. It is going to depend on whether or not if it is lack of benefit I can do it over weeks to months. If it is because I think there is harm or risk it is going to be days to weeks. But in this patient I'm really going to start to focus on non-opioid treatments including non-pharmacotherapies: physical therapy, relaxation, meditation, acupuncture, and so forth. Because I think all too often we have become opioid centric; that is, focusing solely on opioids to treat chronic pain over many years when we now know that these other modalities can help. Not only can they help the person's pain and function, but they can help us treat patients like this with lower doses of medications including opioids.

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So in summary, be clear about clinical indications for the opioid taper. If opioid use disorder is suspected, referred for evaluation and addiction specialty care. Engage the patient regarding the tapering plan, provide alternative pain and symptom treatment including engagement in chronic pain self-management, adjust the taper including the doses and intervals as indicated based on the patient's symptoms, and ultimately the patient's well-being should inform the endpoint of the taper.

I hope you have found this module helpful in thinking about tapering opioids in a patient-centered manner. Thank you for your attention.