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4 Articles in this Series
Introduction
Chronic Pain and Its Companions
Opioids & The Taper Talk
Painful Diabetic Neuropathy: Could SCS Replace Pharmacologic Management?
The Links Among Peripheral Arterial Disease, Lumbar Stenosis, and Claudication

Opioids & The Taper Talk

A PAINWeek 2020 virtual meeting highlight with Jeffrey Fudin, PharmD, FCCP, FASHP, Michael Schatman, PhD, CPE, and Jeffrey Bettinger, PharmD

 

For clinicians, the need to talk with patients about tapering of opioids is a frequent, if not daily, challenge.

Since 2012, total opioid prescriptions have been declining markedly, shared Jeffrey Bettinger, PharmD, a pain management clinical pharmacist at Saratoga Hospital Medical Group in Schenectady, NY. He joined two other pain management experts at a PAINWeek 2020 virtual presentation on “The Opioid Taper Caper: Deciphering and Deflating Daily Dilemmas.”

Dr. Bettinger first cited CDC statistics. After a steady increase in overall national opioid prescribing rates beginning in 2006, the total number peaked in 2012 at more than 225 million.  From 2012 to 2018, the rates declined, with the 2018 rates the lowest in the 13 years for which the CDC has data.1 While that sounds like good news, the rates in some areas continue to remain very high.

The debate about whether to taper patients or not is real and ongoing. According to the three experts presenting, an ever-expanding fear linked with prescribing opioids is driven by policies, guidelines, and recommendations and has swung the pendulum from ''opiophilia to opiophobia.” Primary care providers, these doctors say, ''have found themselves in the crosshairs of a hotly contested debate: To taper or not to taper?”

In the current climate, the experts say, the answer is leaning toward the taper end. But many providers need help understanding why that’s so, how to decide, and then how to help their patients manage the tapering. 

What is driving some of these decisions? Dr. Bettinger pointed out that opioid tapering recommendations and de facto dose ceilings have been enacted by 33 states and by private insurers. The National Conference of State Legislatures keeps tabs.2 In his own research, Dr. Bettinger asked providers why they had tapered patients' opioids in the past year. The overwhelming reason? The 2016 CDC guideline.3 Half cited the guideline as a reason while 30% said insurance regulations (data shared at the 2018 mid-year American Society of Health-System Pharmacists).4

Several factors may impact clinical decisions to start an opioid taper, including the lack of a universal morphine equivalent, drug interactions, and pharmacogenetic variability. (Image: iStock)

Reasons to Taper a Patient off of Opioids Are Complex

The question of whether to suggest a taper is complex, added Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, president of Remitigate Therapeutics at the Albany College of Pharmacy, Delmar, NY, and a PPM Editor-at-Large. He cited these issues:

  • Lack of universal morphine equivalent.
  • Specific opioids that should never have an MEDD (methadone, buprenorphine, tapentadol, tramadol)
  • Drug interactions
  • Pharmacogenetic variability.

Dr. Bettinger added that deciding when a taper is appropriate can be challenging. Among appropriate reasons:

  • Abnormal urine or serum drug screen
  • Aberrant behaviors
  • Refusal to trail non-opioid or non-pharmacological modalities
  • Risks begin to outweigh benefits
  • Lack of significant benefit
  • Patient decision

“There are a lot of times I have seen patients who have been on opioids a long time,” Dr. Bettinger explained. “Some want to see if they can reduce them.”

Among the inappropriate reasons:

  • CDC says so
  • Tolerance
  • Stigma or stereotype (“We sometimes bring our own to the table,” Dr. Bettinger said. “Don’t let that dictate.”)
  • Insurance

Types of Opioid Tapers

Tapers may be forced or involuntary, or shared decisions between providers and patients. “For shared, there is not usually a time limit,” Dr. Bettinger explained. The patient and provider agree on a plan and not end goal or time limit is discussed.

For forced, ''We do tend to have specific time limits.” They are usually recommended when there has been aberrant behavior or abnormal UDS or serum screens. Patients don't agree, often, but they still need to be done, he said.

Communication is important no matter the approach. It’s important to explain why the taper is needed, noted Dr. Bettinger, and to reinforce that it is not a punishment but a measure of safety.

For shared decision-making tapers, he suggested cognitive behavioral therapy (CBT) to help with chronic pain reduction while reducing the doses of opioids.

Don’t Forget about the Psychological Impact

Psychological issues are important to consider as well when tapering, said Michael E. Schatman, PhD, CPE, DASPE, adjunct clinical assistant professor at Tufts University School of Medicine and School of Dental Medicine. For involuntary tapers, he said, withdrawal can be an issue and anxiety can peak at the onset.  While guidelines suggest evaluating patients before starting opioid therapy, Dr. Schatman recommends evaluating patients before initiating a taper as well to see who is likely to survive it emotionally and behaviorally.

Tapering, especially forced, can activate PTSD as well as violence, suicide, and seeking opioids on the streets.

He also urged providers not to stigmatize chronic pain patients. Doing so, he said, means that “We are taking marginalized patients and marginalizing them further.” When not cared for properly, he said, ''Patients can also feel abandoned.”  To feel less abandoned, patients need a credible alternative to pain medications, he said. That could be CBT to help them get through. The psychological pain of chronic pain patients cannot be ignored, he emphasized.

“Chronic pain patients whose psychological sequelae are ignored never, ever seem to get better,” he said. He urged providers to consider the consequences of what he calls “abrupt draconian tapers.” It's important to consider which patients will be put at a higher risk with involuntary tapers, Dr. Schatman said.

As part of the Q&A regarding alternate options, Dr. Schatman took issue with the common suggestion of switching patients to buprenorphine. “Is there any long-term evidence?” he asked the audience. “Not even a modicum.”

The Back Story

After their talk, Dr. Bettinger shared with PPM how the presentation topic came about. As the pain management clinical pharmacist working with primary care providers at Saratoga Hospital Medical Group, he has found that many PCPs could use help with "the taper talk." He often found that clinicians were relying on one of two responses when a taper was indicated: ignore the test results or kick the patient out of the practice.

The purpose of the presentation was to review when it is appropriate to initiate a taper and when it is not – and how to handle it, start to finish. Communication is crucial, Dr. Bettinger said. If providers would look at aberrant behavior and abnormal urine screens as cries for help, dealing with the taper management will be easier, he said. He hopes that providers will become more comfortable talking with patients about tapers, no matter why the decision is being made. With practice comes the skill.  

Dr. Bettinger and Dr. Schatman have no relevant conflicts of interest. Dr. Fudin reports serving on several speakers' bureaus or advisory boards; among them, Abbott Laboratories, AcelRx Pharmaceuticals, and Salix Pharmaceuticals.

 

Sources

  1. CDC. US Opioid Prescribing Rate Maps. March 5, 2020. Available at:  www.cdc.gov/drugoverdose/maps/rxrate-maps.html. Accessed September. 15, 2020.
  2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49.
  3. National Conference of State Legislatures: Prescribing Policies: States Confront Opioid Overdose Epidemic. June 30, 2019. Available at:  www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx Accessed Sept. 15, 2020.
  4. American Society of Health-System Pharmacists Midyear Meeting/ Variability in opioid dose tapers among clinicians. December 2, 2018.  
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