Safely Taper Patients off of Prescription Opioids

Tips on How to Safely Taper Patients Off of Prescription Opioids

An Interview with Mark Sullivan, MD, PhD

Executive Director of COPE for Chronic Pain CME; Professor of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, and Clinician, UW Center for Pain Relief

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Beginning in the mid-1990s, the number of people in the United States receiving prescription opioids for the treatment of chronic pain grew exponentially, and in 2012 some 9 million people reported long-term medical use of prescription opioids. In more recent years, however, the limitations and risks of the long-term use of prescription opioids for chronic pain have become apparent, particularly when used at high doses. Yet getting patients to safely taper off of opioids is difficult for a variety of reasons.  

For guidance on opioid tapering, read our interview with COPE’s Executive Director Dr. Mark Sullivan, who has over 25 years of experience treating chronic pain. Dr. Sullivan has directed multiple studies funded by the National Institutes of Health (NIH) and the National Institute on Drug Abuse (NIDA) on the use and effects of prescription opioids, including an ongoing randomized trial of opioid taper support for patients wishing to discontinue opioid therapy.

Q:  Why do health care providers need to understand how to taper their patients off opioids?
A: There’s a large group of patients already on opioids for whom it becomes apparent that they are not doing well, or there are more risks than were assumed or it’s just not achieved its goals. And so providers want to know: What’s the best way to taper? How do I handle this problem? How do I talk to the patient about it? What sort of strategies do I use? 

Q:  When is it appropriate to taper a patient off opioids?
A:  A patient should be tapered off opioids any time that the risks exceed the benefits or when treatment goals are not being met. Risks such as substance abuse or sleep apnea can emerge.  In other cases, the benefits are not what were hoped for: pain relief is not being achieved, or functional improvement is not being achieved.

We really need to look at whether the patient’s life is improved by opioid therapy. For example, if people say they want to do more of a favorite activity, whether it be fishing or playing with their grandchildren or returning to work, and after a reasonable period of time that hasn’t been achieved, that’s a reason to say, “This treatment has not worked, and it’s time to taper and try something else.”

Q:  What are the major principles of tapering?
A:  The process is guided by patient safety above all. When we taper patients, we’re trying to get them to a safer dose. That doesn’t always have to be zero. Lower doses have a well-documented, decreased risk of overdose and death compared to higher doses. 

I recommend that there’s an agreement with the patient when chronic opioid therapy begins about the goal of the treatment and what would constitute success or failure. That means some of the work needs to be done ahead of time, early in the course of opioid therapy. 

We also believe that, particularly in the high-dose opioid subgroup, there are a lot of untreated or undertreated psychiatric disorders that need to be addressed.  Most patients struggle with insomnia and anxiety as they come off opioids. If you know the patient has a history of depression, or post-traumatic stress disorder, opioid taper can make these problems reappear. And that needs to be addressed if the taper is going to be successful.

Q:  What if a patient doesn’t want to taper off opioids?
A:  It’s quite common that when the prescriber decides that the risks exceed the benefits, the patient might not agree. Patients are frequently really afraid of going without their opioids because they’ve often had overwhelming pain and look to the opioids to save them from that. So the prospect of tapering is often frightening for patients.

It is best to taper collaboratively with your patient.  For instance, if you pledge to patients that they will continue to get adequate pain control, patients’ resistance to taper often can be reduced. But sometimes the taper needs to occur despite patient objections. Even in these cases, it is important to stay engaged with the patient and keep the clinical dialogue going.

Q:  Does pain usually increase with tapering?
A:  Pain may increase temporarily. We know from years of tapering opioids in structured pain rehabilitation programs that patients’ pain levels eventually either stay the same or get better with opioid taper. We have had multiple patients at our Center for Pain Relief who have come completely off opioids and who feel much better as a result. There are a lot of success stories out there.

Q:  How often are patients who need to taper dependent on or addicted to opioids? What do you do in those situations?
A: All patients on long-term opioid therapy will be physiologically dependent on opioids, and will therefore experience withdrawal symptoms if their opioids are abruptly discontinued.  Even with a gradual taper, the majority of patients will have some level of difficulty tapering off opioids, ranging from minimal to significant.

Approximately 10 percent of patients on long-term opioid therapy will meet the criteria for Opioid Use Disorder or opioid addiction.  This means that they are not only physiologically dependent on opioids, but also that they cannot control their opioid use, and that it is causing distress and dysfunction in their lives. Addicted patients should generally be maintained on opioids because few can sustain complete opioid abstinence. Currently, two opioids are approved for treating opioid use disorder: methadone, through methadone maintenance programs, or buprenorphine.  Any clinicians prescribing buprenorphine must be certified to prescribe it for opioid use disorder.

Q:  What medicines can help with withdrawal?
A:  For patients who are not opioid-addicted and may tolerate being tapered off opioids, there are a variety of medications to decrease the symptoms of opioid withdrawal: drugs to control diarrhea, drugs to reduce adrenergic outflow from the central nervous system (i.e., the body’s stress response), and drugs to minimize nausea and flu-like symptoms.  

Q:  If patients resist being tapered, why not just cut off their prescription?
A:  It’s very important to not simply drop or discharge or abandon patients who are being tapered. The real risk is that when patients who have become dependent on or addicted to prescription opioids can no longer get them, they will go on the street to get heroin, because heroin is a cheap and available opioid.

Q:  Can we end the prescription opioid epidemic and improve treatment of chronic pain?
A:  We have been in this period of expanding use of opioids for almost 30 years now.  Just as it took a while to wind up this epidemic, it’s going to take us a while to wind it down, which will consist of starting fewer people on opioids, prescribing lower doses to those people who do get opioids, discontinuing opioids when they are not clearly working, and funding and supporting non-opioid treatments. There’s no way to end this epidemic instantly.

There are a wide variety of evidence-based treatments that have been shown to work for chronic pain—they improve function, quality of life, pain level, etc. These treatments range from relaxation training to alternative medicines to acupuncture to cognitive therapy. But they are typically not as available as opioids, which are distributed in pharmacies all over the place, nor are they as well-insured, nor do they offer immediate relief. 

Q:  How can we best train providers to safely manage prescription opioids and tapering?
A:  There are a lot of different CME activities out there. We’ve provided COPE-REMS, an online activity to improve safe opioid prescribing. It is REMS-compliant—meaning it meets the requirements of the FDA’s Risk Evaluation and Mitigation Strategy.    

All opioid prescribers need to be competent at monitoring problems and tapering opioids, because an unfortunate but common part of opioid therapy is that it doesn’t always work and it can become dangerous for patients. Providers need to know when this is happening and what to do when it does happen. Above all, they need to know when to taper a patient, sometimes down to zero.

Additional Resources

Another Version of this Interview

When to Taper Patients Off Opioids: Mark Sullivan, MD, PhD, Outlines Steps for Opioid Tapering (MedPageToday.com, Dec. 16, 2015)