Stopping or Decreasing Opioid Therapy in Patients on Chronic Opioid Therapy

Abstract

With the rising concerns about long-term opioid use, particularly in patients with chronic noncancer pain, more and more patients are being considered for decreased doses or discontinuation of opioid therapy. This is a challenging clinical situation for both patient and clinician and should be presented in a shared decision-making model so that the patient understands the risks of opioid therapy and how the therapy will be discontinued. The patient should be aware of the long-range plan and its milestones. It is imperative that alternate pain control treatments be made available to the patient early, and that the patient never feels abandoned by the healthcare team. There can be many barriers in shared decision-making and multiple discussions between patient and provider may be required. Opioid use should not be decreased sharply or discontinued abruptly, but should be gradually decremented in a process known as tapering. Tapering should be systematic and planned in advance with the patient knowing the steps. Slow tapers (over months) are more comfortable for the patients but may not always be appropriate. There is guidance for planning the taper and the patient should be closely monitored throughout this process. If withdrawal symptoms occur, they can be managed, for example, with lofexidine. Patients should get full support as they explore new pain control options. For patients who have opioid use disorder, addiction counseling may be appropriate. Navigating opioid discontinuation can be slow work, but optimal results occur when the healthcare team works together and respectfully with the patient.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…High-quality data does not exist at this time to support strong recommendations regarding preoperative opioid reduction strategies, so a patient-specific, collaborative approach informed by appropriate expertise is vital. General guidance exists for opioid tapering in patients on chronic opioid therapy, but application to the preoperative setting is not discussed [ 109 , 110 ]. Opioid tapering must always be accompanied by patient education and respectful support from the healthcare team [ 104 , 109 ].…”

“…General guidance exists for opioid tapering in patients on chronic opioid therapy, but application to the preoperative setting is not discussed [ 109 , 110 ]. Opioid tapering must always be accompanied by patient education and respectful support from the healthcare team [ 104 , 109 ]. Transitional pain services or other perioperative pain management specialist consultation is recommended for opioid-tolerant or otherwise high-risk patients by current guidelines and is supported by implementation reports [ 15 , 18 , 111 , 112 , 113 , 114 ].…”

Mental illnesses as a potential risk factor for non‐medical use of prescription opioids: a narrative review

“…As highlighted by Cragg et al ., 17 pain management should be prioritised in patients that are more likely to engage in NUPO and therapeutic indications should be fully evaluated before prescribing opioids. For patients with a mental illness, appropriate pain management should be planned, including appropriate opioid‐tapering regimens where possible 44 . Opioids should be prescribed at the lowest effective dose with concurrent non‐opioid analgesia for the shortest possible timeframe, particularly for patients likely to engage in NUPO 44,45 .…”

What Your Death Certificate Says About You May Be Wrong: A Narrative Review on CDC’s Efforts to Quantify Prescription Opioid Overdose Deaths

“…The CDC findings regarding T40.4 drugs were inconsistent with prescribing data available at the time showing that the volume of fentanyl dispensed by retail pharmacies in the US declined between 2013 and 2016 by 13.2% (from 403,773.3 grams to 350,397.3 grams) [ 72 ]. In the past, CDC analysts have described a close linear relationship between sales volumes of opioids and opioid overdose deaths, showing that whenever sales increase, they are followed by proportional increases in overdose deaths [ 73 - 76 ]. If one assumes that the converse of this also is true, i.e .…”