Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings
An Individually Authored Discussion Paper
Ensuring high-quality, respectful, and appropriate management of chronic non-cancer pain (CNCP) in the context of the U.S. opioid crisis is a critical and complex endeavor. Unfortunately, data regarding the best way to proceed with care for these patients in terms of opioid maintenance or tapering are lacking. The evidence supporting the use of opioids in managing CNCP is weak, and there is now strong evidence that chronic opioid use among CNCP patients can be detrimental, particularly at high doses.
The discussion paper “Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings” focuses on key decision points and available evidence to support tapering strategies for specific patient populations of long-term opioid use being treated for CNCP in the out-patient setting. This document summarizes the key messages from the discussion paper, as well as identified priorities for future research. It must be reiterated that the needs of each patient are unique and should be approached on a case-by-case basis. Clinicians should review the risks and benefits of tapering for each patient and proceed in a way that is informed by individual circumstances.
NOTE: This decision aid serves as a guide. The needs of each patient are unique and should be approached on a case by case
basis. Clinicians should review the risks and benefits with the patient, and decide how to proceed with the tapering process in a
way that is appropriately informed by individual circumstances and should minimize symptoms of opioid withdrawal.
1. Example risks and benefits to consider include suspected OUD, history of opioid overdose, inadequate pain response, lack of functionality improvement, unbearable side effects, concurrent use of other sedatives, high opioid dosages, diagnoses of other medical conditions; if the treatment is harming the patient’s ability to function physically, emotionally, or socially or if the patient is unable to follow the terms of the agreed-upon pain management plan and/or contract.
2. Consider the goals of the taper with the patient. In general, tapering should be continued as long as the benefits continue to outweigh the risks. For example, the best strategy for many patients may be to taper to a lower opioid dose, rather than to abstinence.
3. Development and periodic reevaluation of a pain management plan with the patient throughout the tapering process can reduce patient anxiety. A combination of multimodal elements can be used to manage patient pain during a taper which allow for pain management to be as effective, or possibly more effective, than prior to the taper.
4. Evidence regarding the selection of tapering speed is lacking. The 2019 HHS Guidelines suggest that slower tapers, or a 10% dose reduction per month or slower, as opposed to faster tapers, are generally better tolerated by patients, and especially by those who have been on opioid therapy for a year or longer. When possible, the speed of the taper should be as slow as needed to limit withdrawal symptoms. In addition, in general, the longer the patient has received opioid therapy, the slower the taper should be.
5. Current treatment strategies to manage withdrawal symptoms include the use of alpha-2 adrenergic agonists, antiemetics, antidiarrheal agents, muscle relaxing agents, acetaminophen, and NSAIDs.
6. Pregnant women, youth, patients with behavioral health disorders and those who are co-prescribed other central nervous system depressants deserve special consideration in the tapering process.
7. Other high risk situations include patient history of opioid overdose, when the treatment is harming function, and patient failure to follow the terms of the treatment plan.
8. A taper can be paused but should generally not be reversed, although there are exceptions.
9. Consider the use of the DSM-5 criteria when assessing for OUD.
10. Healthcare professionals who could provide assistance include addiction medicine specialists, behavioral health specialists and pain medicine specialists, among others.
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Tweet this! New from @theNAMedicine! Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy. Read the paper: https://doi.org/10.31478/202008c #NAMPerspectives #OpioidCollaborative
Tweet this! “There is a need for evidence-based tapering strategies to support the diversity of chronic non-cancer pain patient populations.” Members of the #OpioidCollaborative outline future priorities for research: https://doi.org/10.31478/202008c #NAMPerspectives
Tweet this! A patient undergoing an opioid taper may have concerns about the process. In a new #NAMPerspectives, members of the NAM’s #OpioidCollaborative discuss how shared decision-making can reduce fear and improve taper adherence. Read more: https://doi.org/10.31478/202008c