Appropriate tapering or discontinuation of long-term Opioid Use: Guidance by HHS
Opioids are the mainstay of treatment of all kinds of pain and have a significant role to play in pain management. The U.S. Department of Health and Human Services has released a guideline for clinicians for reducing dosages and discontinuing long-term use of opioid analgesics.
Individual patients, as well as the health of the public, benefit when opioids are prescribed only when the benefit of using opioids outweighs the risks. But once a patient is on opioids for a prolonged duration, any abrupt change in the patient’s regimen may put the patient at risk of harm and should include a thorough, deliberative case review and discussion with the patient. The HHS Guide provides advice to clinicians who are contemplating or initiating a change in opioid dosage.
“Care must be a patient-centred experience an 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, M.D., assistant secretary for health. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk of addiction.”
Clinicians have a responsibility to coordinate patients’ pain treatment and opioid-related problems. In certain situations, a reduced opioid dosage may be indicated, in joint consultation with the care team and the patient. HHS does not recommend opioids be tapered rapidly or discontinued suddenly due to the significant risks of opioid withdrawal unless there is a life-threatening issue confronting the individual patient.
Major among the recommendations are:
- Before beginning a taper, patients with serious mental illness, high suicide risk, or suicidal ideation should be referred to a behavioral health provider.
- If patients show signs of opioid misuse, they should be assessed for opioid use disorder. Those meeting the disorder's criteria should be offered medication-assisted treatment.
- Clinicians should advise patients that they're at risk for overdose if they abruptly return to their higher dose. Patients can lose tolerance in as little as a week.
- Tapers commonly involve dose reductions of 5% to 20% every 4 weeks, with longer opioid use requiring longer tapers.
- Clinicians can consider transitioning patients to buprenorphine if they are on high doses and unable to taper, even if they don't meet the criteria for opioid use disorder.
Compiled from published guidelines and practices endorsed in the peer-reviewed literature, the Guide covers important issues to consider when changing a patient’s chronic pain therapy. It lists issues to consider prior to making a change, which includes shared decision-making with the patient; issues to consider when initiating the change; and issues to consider as a patient’s dosage is being tapered, including the need to treat symptoms of opioid withdrawal and provide behavioural health support. For more information, go to: www.hhs.gov/opioids.
For further reference log on to :
Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics - PDF.