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Clinical Challenge: Opioid Tapering

Too much focus on the pill and not enough on the whole person: that’s a key piece missing in the movement to reduce opioids among chronic pain patients, said Beth Darnall, PhD, of Stanford University in Palo Alto, California.

After the CDC issued its 2016 guidelines for chronic pain opioid prescribing, there’s been a big focus to reduce overprescribing, but little understanding of the best way to do so, Darnall noted. Some agencies and companies used the 2016 guideline to push hard dose limits and abrupt tapering, which the CDC later said was inconsistent with its recommendations. Last year, the FDA issued a safety announcement about sudden opioid tapering, and in the fall, federal health officials released a new guide to try to bring a more balanced approach to the tapering process.

For chronic pain patients, cutting back on opioids can lead to serious consequences, especially if tapering is non-consensual, noted W. Michael Hooten, MD, of the Mayo Clinic in Rochester, Minnesota. “These adverse effects may include failing to complete the taper, stopping care, overdosing, suicidal ideation, worsening of depression or anxiety, and increased use of hospital and emergency health services,” he said.

A recent retrospective study conducted by researchers in the Bronx, New York, for example, showed that compared with continuing long-term opioid treatment, pain patients who tapered their opioids were 4.3 times more likely to subsequently terminate care. And a trial in Denmark that tried to evaluate sequential opioid tapering among long-term pain patients reported that the program failed due to a high number of dropouts.

In 2017, researchers conducted a systematic review of 11 randomized trials and 56 observational studies about reducing or stopping long-term opioids in chronic pain. Their conclusion: “Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue long-term opioid therapy and that pain, function, and quality of life may improve with opioid dose reduction.”

“There’s no good system or structure to implement opioid reduction in a way that we have confidence in, that shows we’re supporting patients and improving their health and their lives,” Darnall observed.

“This is where the imperative comes in to focus on voluntary opioid tapering,” she said. “Let’s create the evidence base. Let’s start with a population where we can have the highest level of support and patient engagement.”

That viewpoint has driven the EMPOWER study, a trial of chronic pain patients who want to take fewer opioids. Led by Darnall, the study of 1,365 patients tests three ways to deliver patient-centered opioid tapering:

  • Through group cognitive behavioral therapy for chronic pain
  • Through group chronic pain self-management
  • Through usual care (tapering only)

Patients report symptoms and satisfaction data weekly and monthly throughout the taper.

Before launching EMPOWER, Darnall and colleagues conducted a small community-based trial of chronic pain patients who wanted to reduce opioid use. In that pilot study, physicians taught chronic pain patients about the benefits of reducing opioid use, offering to help patients reduce doses over 4 months. Of 110 eligible patients, 82 agreed to taper opioid dosages. Participants received a self-help booklet about reducing opioid use and a custom tapering program based on their needs.

To lessen withdrawal symptoms, physicians decreased opioid doses up to 5% for up to two dose reductions in the first month. In months 2 to 4, patients were asked to reduce doses by as much as 10% per week, which was adjusted as needed. Physicians monitored patients at least once a month, changing doses as needed.

Of 82 patients in the study, 31 patients dropped out, which is not unusual for a study like this, Darnall noted. But for the 51 patients who finished, the median daily morphine milligram equivalent dropped from 288 mg to 150 mg, with no increase in pain intensity or pain interference. These people had been on opioids a median of 6 years before the study started.

This shows that dose and duration may not be as important as we think, Darnall noted.

“Common lore is that patients taking high dose opioids are unlikely to have successful outpatient opioid taper results — or if they have been taking opioids for years or even decades they will likely have a poor taper response,” she said. “To the contrary, we found that starting dose and duration of use did not predict taper response.”

Another big trial looking at opioid prescribing and tapering strategies focuses on 1,000 Veterans Affairs (VA) patients who have high levels of pain despite opioids. “Many patients don’t want to taper when they join the study, and we don’t require them to taper,” said study leader Erin Krebs, MD, MPH, of the Minneapolis VA Health Care System and the University of Minnesota. “Because opioid dose reduction is the right thing to do for most participants in the study — that is, risks outweigh benefits — study clinicians work to develop a collaborative plan that involves trying other pain management approaches and encourages engagement with tapering.”

In the VOICE trial, researchers are comparing a collaborative physician-pharmacist telecare program against one led by an integrated medical and mental health team that emphasizes non-pharmacological pain management options. Participants on high opioid doses also will be randomized to either a regular step-wise taper or can choose between a regular taper or switching to a different medication (buprenorphine-naloxone). “The study does not require participants to reduce doses, but provides encouragement and support for tapering,” Krebs said.

The goal is to help patients find pain management approaches to reduce their opioid use, Krebs emphasized. “The primary focus really is on the pain management part of that,” she pointed out. “Once you improve pain management and find better solutions, it’s easier to start backing off of opioids.”

Source: MedicalNewsToday.com