The increasing number of opioid overdose deaths over the last decade has resulted in a public health response centered around thoughtful opioid prescribing practices and careful consideration of risk versus benefit when initiating opioids for pain treatment.
In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines around prescribing opioids for chronic pain, recommending clinicians avoid increasing opioid dosages above 90 morphine milligram equivalents (MME) per day without careful clinical justification. The guideline also recommended opioid dose reduction or discontinuation when risks of opioid therapy outweigh benefits.
While the CDC did not mandate discontinuation of opioids already prescribed above the 90 MME threshold, widespread misapplication of these guidelines coupled with concerns of opioid use disorder has resulted in abrupt discontinuation and rapid involuntary tapers for patients on high dose opioids. For some, this change in care has resulted in significant harm such as psychological discomfort, severe withdrawal, worsening pain, and even suicide.
Challenges to Patient-Centric Opioid Reduction
In our conversations with providers, we learned that rapid dose decreases or sudden discontinuation are often a result of clinicians not knowing how to taper safely or how to approach dose reduction conversations with their patients.
Other challenges to discussing opioid dose reduction with patients include:
- Lack of Time & Resources: Primary care providers have expressed concerns with the lack of time, resources, and non-opioid alternatives available to safely reduce a patient’s opioid dose.
- Damage to Patient-Provider Relationship: Conversations around opioid dose reduction can be challenging and emotionally taxing, and the absence of patient agreement on dose reduction may negatively impact the provider-patient relationship.
- Weighing Risks & Benefits: Opioid dose reduction can lead to positive patient outcomes, but there are significant risks as well, with chief concerns being depression, diminished function, increased pain, illicit substance use, overdose, and suicide. Understandably, taking an accurate assessment of risks and benefits of continued opioid therapy is a significant concern for providers and patients.
Effective Strategies for Opioid Reduction
Patient inclusion and an individual approach to treatment are critical to effective and safe opioid dose reduction. Successful experiences incorporate the following key components:
- Empathizing with a patient’s pain experience
- Discussing the risks and benefits of tapering for patient safety
- Tailoring dose reduction percentages and frequencies to the individual patient, since no singular opioid dose reduction protocol has demonstrated positive patient outcomes
- Engaging in open dialogue and shared decision-making with the patient, especially when dose reduction is being recommended despite the patient having taken their opioid medications as prescribed
- Incorporating a multidisciplinary approach leveraging behavioral health support throughout the reduction
- Leveraging a patient-centric decision support tool for opioid tapering
Providers just need the support and tools to determine when tapering is appropriate, effectively engage their patients in treatment plans, and tailor dose reduction protocols to specific patient circumstances. Are your providers equipped to safely taper patients on opioids? Let’s talk.