An HHS guide outlines how providers can begin the opioid tapering process while promoting patient safety and empathy.
Empathy, teamwork, and patient safety must be at the heart of opioid tapering efforts, according to a new guide from the Department of Health & Human Services.
The Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics outlines the team-based care approach medical professionals must take to ensure a safe opioid tapering process.
Opioids, while having led to a major public health crisis, are important medications used to mitigate chronic pain. Patients with chronic pain or those with cancer often benefit from opioids, and medical professionals have maintained that these populations need adequate access to opioids despite the looming epidemic.
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But there are instances in which medical professionals and patients may decide to taper an opioid dosage or wean the patient off the drug altogether, HHS explained. Specifically, patients and providers may consider tapering an opioid when:
- Pain improves
- The patient requests dosage reduction or discontinuation
- Pain and function are not meaningfully improved
- The patient is receiving higher opioid doses without evidence of benefit from the higher dose
- The patient has current evidence of opioid misuse
- The patient experiences side effects that diminish quality of life or impair function
- The patient experiences an overdose or other serious event (e.g., hospitalization, injury),2,5 or has warning
- signs for an impending event such as confusion, sedation, or slurred speech
- The patient is receiving medications (e.g., benzodiazepines) or has medical conditions (e.g., lung disease,
- sleep apnea, liver disease, kidney disease, fall risk, advanced age) that increase risk for adverse outcomes
- The patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear
During those instances, clinicians must ensure they are tapering the opioid safely, looking out for patients’ physical and mental wellbeing.
“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, MD, assistant secretary for health, said in a statement. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”
Opioid tapering can be challenging, HHS explained. It can put the patient in serious risk of extreme withdrawal symptoms. And as a result, a patient undergoing rapid opioid tapering may seek out illicit sources for opioids to reduce withdrawal symptoms.
The decision to taper an opioid must be made with patient input, HHS noted.
“Decisions to continue or reduce opioids for pain should be based on individual patient needs,” the guide authors wrote. “Consider whether opioids continue to meet treatment goals, whether opioids are exposing the patient to an increased risk for serious adverse events or opioid use disorder, and whether benefits continue to outweigh risks of opioids.”
Providers should not insist on opioid tapering, but instead use shared decision-making to arrive at opioid tapering alongside the patient. Providers should avoid dismissing a patient who does not agree with opioid tapering.
Additionally, establishing a healthcare team will be important, especially because tapering an opioid may require tapering of other drugs like benzodiazepines. The decision to taper must be made by both prescribing physicians.
Once physician and patient have decided to taper off the opioid, the provider must commit to teamwork with the patient. Successful opioid tapering will begin with a mental and behavioral health analysis to determine which symptoms could be exacerbated during tapering and to check for opioid use disorder, which could call for different treatment protocol.
Additionally, providers may consider patient education materials that review the risks of opioid overdoses should a patient return to using the full opioid dose after tapering.
Beginning the opioid tapering process will also require providers and patients to agree on a taper rate. The longer the patient has been taking the opioid, the longer the tapering timeline will be. Patients with a long history of using a prescribed opioid may take a slower approach, reducing their prescription by 10 percent each month.
A faster timeline may call for a 10 percent reduction each week. Once the patient has reached the desired opioid dosage, they may begin taking the drug at further time intervals.
Providers must be mindful that tapers may have to be paused to restarted. These instances are not signs of failure, HHS noted, but instead give the patient a chance to acquire new pain management skills.
Throughout the tapering process, providers and patients must review expectations for pain and tapering progress. Patients need not get discouraged if they have to pause the tapering process. Additionally, they need to have a thorough understanding of what the tapering process can look like. Patients might experience withdrawal symptoms, like depression, that can last weeks or months.
On the provider’s end, HHS says patient-centricity will be essential. Providers should acknowledge patient fears about tapering and withdrawal symptoms and ask how they can better serve their patients. Encouraging statements will help establish a baseline of teamwork.
Clinicians should also be checking in on their patients and watching for signs of depression, anxiety, or suicidal thoughts, and collaborate with mental health professionals where applicable. These patients may be likely to return to their original opioid dosage should symptoms become too much, so providers should closely monitor for mental health side effects.
Finally, providers should be mindful of patients for whom tapering is not working. Patients who cannot go through with tapering or who are demonstrating serious withdrawal symptom may in fact have opioid use disorder and need other courses of treatment. Providers should monitor for those issues and refer the patient where necessary.
These recommendations come as the medical industry grapples with the opioid crisis and patient experience. Pain management is essential to quality of life, and many medical professionals believe patients with genuine pain needs should have access to a prescribed opioid.
But as opioid misuse grips the nation, medical providers have struggled to ensure judicious opioid use while quelling opioid overprescribing. This latest guideline is a new step for HHS and outlines its priorities for tapering opioid use.
Source: Patient Engagement Hit