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Opioid Tapering Guidelines and Conversation Starters

May 4, 2021

Robin R. Ockey M.D.

Intermountain Project ECHOPain Management

Disclosure

I have no financial interest to disclose

Objectives

1. Analyze current tapering guidelines

2. Apply conversation starters to initiate an opioid taper

The Opioid Epidemic

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates (accessed 4/18/2021)

https://www.cdc.gov/drugoverdose/epidemic/index.html (accessed 4/18/2021)

Number of Overdose Deaths in Utah (by opioid category)

NIDA. 2020, April 3. Utah: Opioid-Involved Deaths and Related Harms. Retrieved from https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/utah-opioid-involved-deaths-related-harms on 2021, April 25

Overdose Deaths and Opioids(United States vs Utah)

When considering all opioids (prescription and nonprescription), of the 39 states (includes District of Columbia) with good or very good-excellent reporting, 22 states had a death rate worse than Utah (in other words, Utah was the 23rd worst state out of 39).

WHEN CONSIDERING PRESCRIPTION OPIOIDS, only 1 out of these 39 states had a worse death rate than Utah (West Virginia).

Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018. MMWR Morb Mortal Wkly Rep 2020;69:290–297. DOI: http://dx.doi.org/10.15585/mmwr.mm6911a4

2018 Overdose rate (per 100,000) • With involvement of any opioid: 14.6 vs 14.8• Prescription opioids: 4.5 versus 10.5

Prescribing Rates in 2018 (prescriptions per 100 persons)

• Only 5 states had a higher prescribing rate for ≥ 50 MME <90 MME than Utah

• Only 3 states had a higher prescribing rate for > 90 MME than Utah

All Opioid Prescriptions

U.S. Rate:

51.4

Utah Rate:

57.1

< 50 MME

U.S. Rate:

39.7

Utah Rate:

38.9

≥ 50 MME < 90 mg MME

U.S. Rate:

7.9

Utah Rate:

11.6

≥ 90 MME

U.S. Rate:

3.9

Utah Rate:

6.7

Centers for Disease Control and Prevention. 2019 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States Surveillance Special Report. Published November 1, 2019.

Reasons to Taper

Reasons to Taper or Discontinue Opioids • Pain improves or resolves

• Opioids not improving pain or function enough to justify use

• Patient wants to reduce the dose or discontinue

• Patient is taking a higher dose without evidence that there are benefits from the higher dose

• There is current evidence of opioid misuse

• Side effects occur that decrease quality of life or impair function

• Patient experiences an overdose or other serious event (e.g., hospitalization, injury), or has warning signs of risk for overdose such as confusion, sedation, or slurred speech

• Patient is taking medications that increase the risk (like benzodiazepines)

• Patient has medical conditions (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) that increase risk for bad outcomes

• Patient has been treated with opioids for a prolonged period, and it is unclear that current benefits outweigh risks/side effects

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services, October 2019https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf

When Discontinuation May Be Required

• Injecting, snorting, selling, stealing, forging, sharing, borrowing, concurrent use of illicit drugs, taking differently than prescribed, obtaining from other prescribers, reports of frequently losing or having prescriptions stolen

Inappropriate Use

• Includes the above. Refusal to obtain urine drug screening. Inappropriate urine drug screen. Aggressive behavior towards clinic staff. Presenting to ED repeatedly for pain management.

Breach of medication management agreement

• Motor vehicle accent due to impairment/DUI, hospitalization for overdose, development of opioid use disorder

Miscellaneous

Reasons for Discontinuation of Long-Term Opioid Therapy (LTOT) in VA Patients

Only 15.2% of the time, discontinuation initiated by the patient (N = 91)

Patient-initiated reasons Full sample, % (n)

Concern about developing addiction or belief one was already addicted to opioids 4.3% (26)Opioids not effective at relieving pain 2.7% (16)Adverse opioid side effects 2.3% (14)Managing pain with nonopioid modalities 1.8% (11) Concern from family members about continued opioid use 1.0% (6) No patient reason documented in the medical record 2.5% (15)Other 1.3% (8)

Patients may have been discontinued for more than one reason; therefore, column percentages do not add to 100%.

Lovejoy TI, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Dobscha SK. Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain. 2017;158:526-534.

Reasons for Discontinuation of Long-Term Opioid Therapy (LTOT) in VA Patients84.8% of the time, discontinuation initiated by the clinician (N = 509)Clinician initiated reasons Full sample, % (n)Aberrant behaviors 63.7% (382)

Known or suspected substance abuse 43.7% (262)Aberrant urine drug test 37.2% (223)Opioid misuse 15.3% (92)Nonadherence to pain plan of care 11.3% (68)Known or suspected opioid diversion 3.5% (21)

Patient safety concerns 6.2% (37)High risk for an opioid-related adverse event 2.5% (15)Opioids contraindicated with other medications 2.5% (15)Patient opioid-related overdose 1.5% (9)

Lack of efficacy 5.0% (30)Opioids not indicated for type of chronic pain 3.2% (19)Opioids not decreasing pain 2.0% (12)Opioids not improving functioning 0.8% (5)

Opioids now prescribed by non-VA provider 6.7% (40)No clinician reason documented in the medical record 10.8% (65)Other 1.2% (7)

Column percentages do not add to 100% because discontinuation may have been for more than one reason.Lovejoy et al. 2017

Poll: Tapering may be appropriate in all of the following situations except:A. Pain has resolvedB. Functional improvement is insufficient to justify use of the

opioid.C. It has been confirmed that the patient is diverting their opioid

medication rather than taking it.D. Side effects from the opioid are occurring that impact quality of

life/impair function.E. New medications have been started that increase the risk of

opioid induced respiratory depression to the extent that it is no longer felt that benefits of opioids outweigh the risks.

What are the risks?

Important Considerations• In 2019 the FDA reported receiving reports of serious harm with sudden discontinuation/rapid taper of opioids

in physically dependent patients. Harms included “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”(1)

• Another study found that after “controlling for sociodemographic and clinical factors, each additional week of discontinuation time was associated with a 7% reduction in the probability of having opioid related adverse event”(2)

• Various studies demonstrate association between discontinuation of long-term opioid use and increased risks of suicide/self-harm and overdose. (2,3,4)

• In a study of just under 1,400,000 patients on chronic opioid therapy, the risks of death by suicide and overdose were higher in patients who stopped opioid treatment (and the risk increased the longer the patient had used opioids). (3)

1. Food and Drug Administration (2019). FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering FDA Drug Safety Communication. https://www. fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-suddendiscontinuation-opioid-pain-medicines-and-requires-label-changes2. Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. J Subst Abuse Treat. 2019 Aug;103:58-633. Oliva E M, Bowe T, Manhapra A, Kertesz S, Hah J M, Henderson P et al. Associations between stopping __prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation BMJ 2020; 368 :m2834. James JR, Scott JM, Klein JW, Jackson S, McKinney C, Novack M, Chew L, Merrill JO. Mortality After Discontinuation of Primary Care-Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study. J Gen Intern Med. 2019 Dec;34(12):2749-2755.

Important Opioid Tapering Considerations from VA Guideline

• “Provide opioid overdose education and prescribe naloxone to patients at increased risk of overdose.”

• “Strongly caution patients that it takes as little as a week to lose their tolerance and that they are at risk of an overdose if they resume their original dose.”

• “Patients are at an increased risk of overdose during this process secondary to reduced tolerance to opioids and the availability of opioids and heroin in the community.”

Pain Management Opioid Taper Decision Tool, A VA Clinician’s Guide. Accessed 4.18.2021 at https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Academic_Detailing_Educational_Material_Catalog/52_Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf#.

Per HHS Oct 2019:“Avoid misinterpreting cautionary dosage thresholds as mandates for dose reduction. While, for example, the CDC Guideline recommends avoiding or carefully justifying increasing dosages above 90 MME/day, it does not recommend abruptly reducing opioids from higher dosages. Consider individual patient situations”

“There are serious risks to noncollaborative tapering in physically dependent patients, including acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, and patients seeking opioids from high-risk sources”

“Tapering is more likely to be successful when patients collaborate in the taper”*HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services, October 2019https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf

Poll: Which of the following is true regarding tapering:A. Education about opioid overdose is less important because the dose is

being tapered.B. Naloxone does not need to be prescribed because the patient is

coming off of the opioid.C. Though harmful in some ways, tapering non-collaboratively is

important because it gets people off of opioids and the risk of being on opioids outweighs the harm of non-collaboratively tapering

D. Rapid tapers/quick discontinuation is less risky than longer tapers.E. Risk of suicide and overdose death is higher in patients who have

recently stopped opioid medication and that risk increases in patients who have been on opioids longer.

Tapering considerations:

Taper Preparation/Considerations• Depression is associated with dropout from tapering and relapse of opioid use. (1)

• Depression may even be a stronger risk factor than is SUD for resumption of opioid use after interdisciplinary chronic pain rehabilitation. (2)

• Assess for opioid use disorder (OUD). If OUD is identified, consider engaging someone experienced in the management of OUD.

• Utilize shared decision making in the process. Tapering is more likely to be successful if patients are motivated to adhere to the plan. Expert opinion suggests that the decision to taper must be part of a collaborative and compassionate plan that avoids rapid/forced tapers requiring aggressive opioid dose reductions over defined periods (even extended periods). (3)

1. Heiwe S, Lönnquist I, Källmén H. Potential risk factors associated with risk for drop-out and relapse during and following withdrawal of opioid prescription medication. Eur J Pain. 2011 Oct;15(9):966-70.2. Huffman KL, Sweis GW, Gase A, Scheman J, Covington EC. Opioid use 12 months following interdisciplinary pain rehabilitation with weaning. Pain Med. 2013 Dec;14(12):1908-173. Darnall BD, Juurlink D, Kerns RD, et al International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced OpioidTapering, Pain Medicine, Volume 20, Issue 3, March 2019, Pages 429–433, https://doi.org/10.1093/pm/pny228

Discontinuation and Tapering of Opioid Medications in Chronic Pain Patients

• Discontinuation and tapering are not the same thing.

• Tapering may be part of the process of discontinuation but it also could be part of the process of lowering the dose

• Should be considered as an option at every visit.

• Per CDC guideline 2016: “If patients receiving opioid therapy for chronic pain do not experience meaningful improvements

in both pain and function compared with prior to initiation of opioid therapy, clinicians should consider working with patients to taper and discontinue opioids”

Discontinuation/Tapering of Opioid Medication• Physical dependence can occur with even short term exposure to an opioid. This is manifested by withdrawal.

• Evidence to guide specific recommendations on the rate of reduction is lacking, though a slower rate may help reduce the unpleasant symptoms of opioid withdrawal.” [1]

• Some have proposed rapid tapers initially that are slowed as doses reach lower levels.

• According to the CDC 2016 guideline, “patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.” [2]

• When/If OUD is discovered, this needs to be addressed (may include medication assisted treatment rather than discontinuation).

1. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-30.

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. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1

Patient Perspective about Tapering Chronic Opioid Therapy (COT)

• Perceive tapering as difficult/anxiety provoking.

• Believe that there is low risk of overdose.

• Are more concerned about the immediate risk of increased pain.

• Barriers to tapering include:A perceived lack of effectiveness of non-opioid options in managing painFear of opioid withdrawal

• Patients who have undergone tapering report that social support and a trusted healthcare professional are important to the tapering process.

Joseph W. Frank, Cari Levy, Daniel D. Matlock, Susan L. Calcaterra, Shane R. Mueller, Stephen Koester, Ingrid A. Binswanger; Patients’ Perspectives on Tapering of Chronic Opioid Therapy: A Qualitative Study, Pain Medicine, Volume 17, Issue 10, 1 October 2016, Pages 1838–1847

Poll: Which of the following is not a barrier with opioid tapering:A. The idea of tapering is anxiety provoking to the patientB. The patient’s belief that the risk of overdose is low.C. Patients are generally more concerned about the

immediate risk of increased pain than the potential harms of opioid medication.

D. The patient’s belief that non-opioid strategies in pain management are not as effective as opioids

E. A trusted healthcare professional collaborating with the patient on the tapering process

F. The fear of withdrawal

Provider Strategies to Enhance Opioid Tapering Success• Educate patients about the risk of

overdose even when medication is taken as prescribed

• Voice intent to manage pain during and after opioid tapering

• Review previously tried pain management strategies and determine barriers to non-opioid strategies

• Evaluate patient’s experience with opioid withdrawal

• Identify /engage social supports

• Emphasize potential quality of life improvement with tapering/ discontinuing

• Be available for close follow-up• Offer detailed instructions on medication

changes• Assure other psychological support

strategies

“Providers were praised for attributes such as being supportive, nonjudgmental, flexible, and accessible.”

Note: “Patient–provider interactions have been identified as barriers but also as facilitators of positive patient outcomes once trust is established”

Joseph W. Frank, Cari Levy, Daniel D. Matlock, Susan L. Calcaterra, Shane R. Mueller, Stephen Koester, Ingrid A. Binswanger; Patients’ Perspectiveson Tapering of Chronic Opioid Therapy: A Qualitative Study, Pain Medicine, Volume 17, Issue 10, 1 October 2016, Pages 1838–1847

Possible results of voluntary reduction of long-term opioid dosages

• Many patients report improved function, sleep, anxiety, and mood without worsening pain and some patients describe decreased pain (1,3,4,5,6,7,8)

• Unfortunately, some patients report increased pain, insomnia and depression (1,3,4,6,9)Increased pain can result from withdrawal or from the hyperalgesiaDuration of increased pain in both situations is unpredictable and may be prolonged in some patients

• The decision to discontinue or reduce opioids taken for pain should be based on individual circumstances. (1,2,10)

1. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics 2019 Oct https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf

2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. 2016 Mar 18;65(1):1-49. 3. Kroenke K, Alford DP, Argoff C, et al. Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report. Pain Med.

2019 Apr 1;20(4):724-735. 4. Berna C, Kulich RJ, Rathmell JP. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice. Mayo Clin Proc. 2015

Jun;90(6):828-42. 5. Darnall BD, Ziadni MS, Stieg RL, Mackey IG, Kao MC, Flood P. Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain. JAMA Intern Med.

2018 May 1;178(5):707-708. 6. Goesling J, DeJonckheere M, Pierce J, Williams DA, Brummett CM, Hassett AL, Clauw DJ. Opioid cessation and chronic pain: perspectives of former opioid users. Pain. 2019

May;160(5):1131-1145. 7. Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Ann Intern Med. 2017 Aug

1;167(3):181-191. 8. Sullivan MD, Turner JA, DiLodovico C et al. Prescription Opioid Taper Support for Outpatients with Chronic Pain: A Randomized Controlled Trial. J Pain. 2017 Mar;18(3):308-

318. 9. Manhapra A, Arias AJ, Ballantyne JC. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Subst Abus. 2018;39(2):152-161. 10. U.S. Department of Health and Human Services. Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations.

May 2019. Available at https://www.hhs.gov/ash/advisorycommittees/pain/index.html.

If Dose Reduction and Possible Discontinuation Is the plan:• Managing pain during and after tapering is a priority

• Efforts will be made to try and avoid withdrawal

• We will be available to answer concerns and help as much as possible in the process

• Provider/patient collaboration is important

• Psychological support may be an option and is often helpful

• Maximizing social support in the process is also important

Determine Tapering Schedule• Slower, more gradual tapers are often the most tolerable and can be completed over

several months to years based on the opioid dose.

• The longer the duration of previous opioid therapy, the longer the taper may take.

• Example tapers for opioids:Slowest taper (over years). Reduce by 2 – 10 % every 4 – 8 weeks with pauses in the taper as

needed.Slower taper (over months or years). Reduce by 5 – 20 % every 4 weeks with pauses in taper as

needed. (Most common taper)Faster taper (over weeks). Reduce by 10 – 20 % every week.Rapid taper (over days). Reduce by 20 – 50 % of first dose if needed; then, reduce by 10 – 20 %

every day.

Pain Management Opioid Taper Decision Tool, A VA Clinician’s Guide. Accessed 4.18.2021 at https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Academic_Detailing_Educational_Material_Catalog/52_Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf#.

When Tapering: Evaluate Pain/Function, Mood and for Evidence of Withdrawal With Every Visit

Evidence for withdrawal:• Consider short-term pharmacological strategies• Consider slowing/pausing the taper• Consider psychological support

Problems with Mood:• Address anxiety and / or depressiono Note: Avoid adding a benzodiazepine given the

potential for interaction with opioids• Consider consultation with:o Psychiatristo Psychologisto Other support, such as a care manager

Increased Pain/Reduced Function:• Non-opioid drugs:o Anti-inflammatorieso Anti-epilepticso Antidepressants

• Nonpharmacologic strategies:o Mindfulnesso CBTo Massage therapyo Living Well with Chronic Pain self-management class (usually

free to the patient)

• Referral to a care manager for support and education

Avoiding withdrawal: A significant reason for ongoing opioid use

• 653 participants seeking treatment for dependence upon prescription opioids studied.

• One of the exclusion criteria: If a prescribing clinician believed that the participant's pain was of sufficient severity that

ongoing opioid therapy was warranted.

• Among the subgroup of patients who reported pain relief as the primary initial reason for prescription opioid use, the primary current reasons for use were as follows:56.5%: Avoiding withdrawal22.6%: Pain relief13.9%: Getting high

Weiss RD, Potter JS, Griffin ML, et al. Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain. J Subst Abuse Treat. 2014;47(2):140-5..

Short-term oral medications can be used to help with withdrawal symptoms (especially during fast tapers)Symptoms Treated Pharmacological Treatment Options:Autonomic symptoms(sweating, tachycardia, myoclonus)

First lineClonidine 0.1 to 0.2 mg oral every 6 to 8 hours; hold dose if blood pressure <90/60 mmHg (0.1 to 0.2 mg 2 to 4 times daily is commonly used in the outpatient setting)• Recommend test dose (0.1 mg oral) with blood pressure check 1 hour post dose; obtain daily blood pressure checks; increasing dose requires additional

blood pressure checks• Re-evaluate in 3 to 7 days; taper to stop; average duration 15 days.AlternativesBaclofen 5 mg 3 times daily may increase to 40 mg total daily dose • Re-evaluate in 3 to 7 days; average duration 15 days• May continue after acute withdrawal to help decrease cravings• Should be tapered when it is discontinued (i.e. do not abruptly stop)Gabapentin start at 100 to 300 mg and titrate to 1800 to 2100 mg divided in 2 to 3 daily doses (adjust dose if renal impairment)• Can help reduce withdrawal symptoms and help with pain, anxiety, and sleepTizanidine 4 mg three times daily, can increase to 8 mg three times daily

Anxiety, dysphoria, lacrimation, rhinorrhea

Hydroxyzine 25 to 50 mg three times a day as neededDiphenhydramine 25 mg every 6 hours as needed (avoid if over 65 years of age).

Myalgias NSAIDs (e.g., naproxen 375 to 500 mg twice daily or ibuprofen 400 to 600 mg four times daily). Caution in patients with risk GI bleed, renal compromise, cardiac disease or liver disease.Acetaminophen 650 mg every 6 hours as needed (avoid in liver disease).Topical medications like menthol/methylsalicylate cream, lidocaine cream/ointment

Sleep disturbance Trazodone 25 to 300 mg orally at bedtime (depends on patient and other medications that the patient may be taking)Nausea Prochlorperazine 5 to 10 mg every 4 hours as needed

Promethazine 25 mg orally or rectally every 6 hours as neededOndansetron 4 mg every 6 hours as needed

Abdominal cramping Dicyclomine 20 mg every 6 to 8 hours as neededDiarrhea Loperamide 4 mg orally initially, then 2 mg with each loose stool, not to exceed 16 mg daily

Bismuth subsalicylate 524 mg every 0.5 to 1 hour orally, not to exceed 4192 mg/dayU.S. Department of Veterans Affairs. Opioid Taper Decision Tool. https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

• Though infrequently, I may use some of these medications to treat symptoms of withdrawal, this is unusual. I rarely end up treating withdrawal pharmacologically because typically I prescribe tapers that are slow enough that withdrawal is not an issue.

• Though these medications were recommended for withdrawal in this publication, I would caution you to remember that some of these medications could interact with the opioid that is being tapered. For example—see the warning by FDA from December 2019 regarding combining gabapentinoids with other central nervous system depressants including opioids.

https://www.fda.gov/drugs/fda-drug-safety-podcasts/fda-warns-about-serious-breathing-problems-seizure-and-nerve-pain-medicines-gabapentin-neurontin#:~:text=On%20December%2019%2C%202019%20FDA,who%20have%20respiratory%20risk%20factors.

Dose=

Risk

Increased Risk for Serious Overdose

Opioid Dose Hazard Ratio for Serious Overdose Events

None 0.19

1 to <20 MME per day 1.00

20 to <50 MME per day 1.19

50 to <100 MME per day 3.11

≥100 MME per day 11.18* Serious overdose events included:

• Death• Series nonfatal events (requiring hospitalization, unconsciousness, respiratory failure)

Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92

Increased Risk for Death from Overdose

Opioid Dose Hazard Ratio

1 to <20 MME per day 1.00

20 to <50 MME per day 1.88

50 to <100 MME per day 4.63

≥100 MME per day 7.18

Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011 Apr 6;305(13):1315-21

More Information about Dose (from 2 additional studies)

• There is no dose under which risk is completely eliminated.

• Should not look just at dosage ranges (Like 20-50 MME). --Risk increases as dose increases even within these ranges.

• Going back and forth from one dose to another also increases risk. (could occur when someone repeatedly tries to taper unsuccessfully)

--Providers need to be involved with tapering or discontinuation efforts!

1. Bohnert AS, Logan JE, Ganoczy D, Dowell D. A Detailed Exploration Into the Association of Prescribed Opioid Dosage and Overdose Deaths Among Patients With Chronic Pain. Med Care. 2016;54(5):435–4412. Glanz JM, Binswanger IA, Shetterly SM, Narwaney KJ, Xu S. Association Between Opioid Dose Variability and Opioid Overdose Among Adults Prescribed Long-term Opioid Therapy. JAMA Netw Open.

2019;2(4):e192613. Published 2019 Apr 5.

Dose Matters!!

• Overdose risk• Opioid use disorder• Depression• Fracture• Motor vehicle accident• Suicide

Higher opioid doses are associated with an increased risk of:

• Decreasing the dose or discontinuing the opioid may lower risks

Opioid taper

1. Bohnert AS, Valenstein M, Bair MJ, et al. 2011 2. Dunn KM, Saunders KW, Rutter CM, et al. 2010 3. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink, DN. 2011 4. Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. 2014 5. Scherrer JF, Svrakic DM, Freedland KE, Chrusciel T, Balasubramanian S, Bucholz KK et al. 2014 6. Saunders KW, Dunn KM, Merrill JO, Sullivan M, Weisner C, Braden JB, et al. 2010 7. Gomes T, Redelmeier DA, Juurlink DN, Dhalla IA, Camacho X, Mamdani MM. 2013 8. Ilgen MA, Bohnert AS, Ganoczy D, Bair MJ, McCarthy JF, Blow FC. 2016 9. Bohnert AS, Valenstein M, Bair MJ. JAMA. 2011 Apr 6;305(13):1315-21

CDC Guideline Recommendations (2016)• Use caution when prescribing opioids at any dose

• Reassess benefits and risks when increasing dose to ≥ 50 mg morphine equivalents

• Avoid increasing the dose to ≥ 90 mg morphine

• “Clinicians should calculate the total MME/day for concurrent opioid prescriptions to help assess the patient’s overdose risk (see Recommendation 5). If patients are found to be receiving high total daily dosages of opioids, clinicians should discuss their safety concerns with the patient, consider tapering to a safer dosage”

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.

2 Important Recommendations from 2016 CDC Guideline(i.e. Tapering/discontinuation should be discussed when first considering COT)

• “Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.”

Recommendation #2

• “Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.”

Recommendation #7:

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. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1

From 2016 CDC Guideline (regarding tapering):Patients already taking high doses of opioids and patients transferring from other clinicians:

• Even considering reduction may be anxiety provoking for the patient

• Especially challenging after years of being on high doses (because of both physical and psychological dependence)

• Should be offered the opportunity to reevaluate opioid use in light of recent evidence regarding the association of dose and overdose risk

• Clinicians should explain in a nonjudgmental manner to patients already taking high opioid dosages (≥90 MME/day) that there is now an established body of scientific evidence showing that overdose risk is increased at higher opioid dosages.

• Should empathically review benefits and risks of continued high-dosage opioid therapy and should offer to work with the patient to taper opioids to safer dosages.

• For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan

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. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1

“… patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.”

Additional Opioid Tapering Considerations (from CDC)• Tapering plans may be individualized based on patient goals and

concerns. • Tapers might have to be paused and restarted again when the

patient is ready • Tapers might have to be slowed once patients reach low dosages. • Tapers may be considered successful as long as the patient is

making progress. • Once the smallest available dose is reached, the interval between

doses can be extended. • Opioids may be stopped when taken less frequently than once a

day. 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. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1

From: HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesicshttps://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf (accessed 12/27/2019)

• An algorithm/flow chart was published by Health and Human Services regarding opioid tapering. • A suggestion was made that in situations where benefits do not outweigh risks and where tapering is

unsuccessful that buprenorphine be considered in patients with or without opioid use disorder.

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