Patients on Chronic Opioids: How and When to Taper
Prescribing Opioids in 2018: Reduce, Reduce and Replace Saturday April 14, 2018 Kelly Bossenbroek Fedoriw, MD Opioid Crisis? Kral LA, Jackson K, Uritsky T. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.
Objectives Overview of opioid crisis with the patient at the center Know how to counsel patients pre and postop about opioids and their disposal Be familiar with ways to taper opioids Commit to learning more about MAT for opioid use disorder How many pills for a lap chole?
Median rx was 250mg, median use was 30mg 42 73% of opioid pills post-op go unused > 70% are not stored in locked container Introduced guidelines and reduced excessive pills and did not increase refill requests (and pts continued to take <50%!) Reduce the number of pills in circulation Bicket M, Long J, Pronovost P et al. Prescription opioid analgesics commonly unused after surgery: A systematic review. JAMA Surg. doi:10.1001/jamasurg.2017.0831 Howard R, Waljee J, Brummett C, Englesbe M et al. Reduction in opioid prescribing through
evidence-based prescribing guidelines. Jama Surg. doi:10.1001/jamasurg.2017.4436 Reduce the Exposure and Supply Prepare your patient for pain Ask: What do you do when you have pain? Make a plan How many did you take? Do you have any left over? How did you dispose of them?
Disposal Offer alternatives for disposal. Find out where there are disposal centers. UNC Across NC And then get Deterra bags! www.ncdoj.gov Reduce total dose
Overdoses are NOT just due to addiction and misuse CDC Guideline for Prescribing Opioids for Chronic Pain Reduce total dose Uncoupling of CO2 drive at high doses, even if taken appropriately
CDC Guideline for Prescribing Opioids for Chronic Pain Bohnert A, Valenstein M, Bair M, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA April 6, 2011. 305:13, 1315-1321 Reduce total doses Overdose risk doubles at 50MME Overdose death rate per 1000 person-months Dose
Chronic Pain Acute Pain Subs Use Disorders 20-49 MME
0.24 0.36 0.78 50-99 MME 0.66
1.13 1.59 1.82 2.97 >100 Taper
patients MME 1.24 CDC Guideline for Prescribing Opioids for Chronic Pain Bohnert A, Valenstein M, Bair M, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA April 6, 2011. 305:13, 1315-1321 NC Medicaid pts on high doses Percent of NC Medicaid claims for prescriptions
of long acting opioids: 91 MME 120 MME/day = 13.7 % > 120 MME/day = 22.3% Total on HIGH DOSE = 36% of pts on long acting opioids Total of 14,600 patients in NC Reasons to Consider a Taper
Lack of Efficacy No improvement in function Inadequate analgesia Failure to reach established treatment goals Opioid-related adverse effects Cognitive compromise or sedation
Refractory constipation or urinary retention Concerns about respiratory depression Hypogonadism or osteoporosis Opioid-induced hyperalgesia Unacceptable risk Obtaining opioids from multiple providers Inappropriate urine drug screen results Compulsive overuse Noncompliant, misusing or abusing Taking benzodiazepines concurrently
Kral LA, Jackson K, Uritsky T. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102. Who needs to Taper? No sporadic use, prn basis Yes - patients that use long-acting and/or short-acting agents as a regular daily regimen ( 50 MME/day) There is no single strategy for tapering opioids. The literature is highly variable in dose reductions and
schedules for opioid tapers across a variety of published guidelines. Kral LA, Jackson K, Uritsky T. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102. 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):149. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1 Approaches to Tapering Slow taper is better for most patients
Individualize rate and duration of the taper to the patient Its suggested to decrease dose by 10-20% weekly or monthly and then more slowly as dose reaches 30-45 mg MME/day to avoid withdrawal. Increased monitoring (visits) is likely necessary Kral LA, Jackson K, Uritsky T. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.
Approaches to Tapering Rapid Tapering may be necessary when it is not safe to further prescribe opioids To avoid serious withdrawal, reduce dose by 25% every few days. The patient should be counseled on withdrawal symptoms and consider medications for the
management of opioid withdrawal symptoms Kral LA, Jackson K, Uritsky T. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102. Withdrawal Symptoms VA Opioid taper decision tool. Washington, DC: Veterans Administration; 2016, Available from: https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P 96820.pdf Pharmacologic management of opioid
withdrawal symptoms Kral LA, Jackson K, Uritsky T. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102. Considerations Optimize evidence-based nonopioid analgesics to manage pain Gabapentin, pregabalin, APAP, NSAIDs, TCAs, Skeletal muscle relaxants, etc
Coordinate with specialists and treatment experts as needed Make sure patients receive appropriate psychosocial support Let patients know that most people have improved function without worse pain after tapering opioids. Some patients even have improved pain after a taper, even though pain Dowell D, Haegerich Chouworse R. CDC Guideline
for Prescribing Opioids for Chronic Pain might brieflyTM,get at first. United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):149. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1 Is it possible? 110 eligible patients in outpt pain clinic 82 agreed to participate 51 completed a 4 month taper
Median MME decreased from 288 to 150 No behavioral health support Darnall B, Ziadni M, Stieg R, et al. Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain February 19, 2018. doi:10.1001/jamainternmed.2017.8709. 62 yr old man with severe DDD H/o severe cervical DDD, s/p surgery for stenosis 6 yrs ago
Currently taking oxycontin 120mg qAM, 80mg at noon, 120mg qPM and oxycodone IR 10mg QID prn. Also taking ambien prn sleep and valium 5mg TID for muscle spasms Should he be tapered? How? Treatment failure - Unacceptable risk Very high dose opioids (MME 540), pt
reporting very limited function as well as uncontrolled pain Concurrent benzodiazepines: ambien and valium Step 1: stop ambien and transition to trazodone Step 2: taper valium by 5mg every month over 3 months to off and start baclofen instead
Original MME: 540 oxycontin 20mg/week for 4 weeks, pt seen weekly oxycontin 20mg/month x 4 months, pt seen monthly oxycontin 10mg/month x 6 months, pt seen q 2 mo more slowly the oxycodone IR 10mg QID to 5mg daily prn 5 yrs later: MME 158 Oxycontin 40mg AM, 40mg noon, 20mg PM, 5 daily prn
Has naloxone kit at home, knows how to use it No ambien, no valium No decrease in function, no increase in pain . Therapeutic Alliance Give pt choices Focus on relationship Provide support for mental health
48 yr old woman with uncontrolled depression, OSA, chronic non-specific low back pain Current medications: Cymbalta, MS contin 60mg TID, oxycodone 10mg QID prn MME = 240 Do you taper her? How? Lack of indication for opioids / unacceptable risk
Treat depression/OSA include your specialists when necessary Slowly taper opioids Original MME: 240 MS contin by 10mg/mo x 9 months (now 30mg TID) oxycodone to TID instead of QID MS contin by 15mg and inc oxycodone to
QID for that month, then back to TID 3 yrs later: MME 105, still going down MS contin 30mg BID, oxycodone 10mg TID prn Has naloxone kit at home, knows how to use it No decrease in function, no increase in pain Compassionate Care Always try to talk to a patient directly about unexpected results (urine tox screens etc)
Dont stop a patients medications via letter. Attempt a phone call, offer to keep caring for them. Stopping opioids doesnt mean discharge from practice Offer help or referral for misuse and addiction. There are good treatments!! Replace Learn more about Opioid Use Disorder and
Medication Assisted Treatment Buprenorphine/Naloxone (Suboxone, Zubsolv etc) is the most well known, but not the only treatment available Become a provider. Training is free. http://www.aoaam.org/?page=PCSSMAT NC Ranks High on Abuse but Low on Treatment MAT works! Improve patient survival
Increase retention in treatment Decrease illicit opiate use and other criminal activity among people with substance use disorders Increase patients ability to gain and maintain employment Improve birth outcomes among women who have substance use disorders and are pregnant Decrease relapse Lower risk of contracting HIV or hepatitis C Join ECHO!
Conclusion Reduce the supply and diversion by talking with your patient about acute pain Help patients dispose of medications appropriately Taper patients compassionately Learn more about Opioid Use Disorder and Medication Assisted Treatment
Patient with no opioid in utox CONFIRM, CONFIRM, CONFIRM Make sure you are testing for the right opioid and know your metabolites. When in doubt, call the lab Fentanyl is separate test, get a confirmation!
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