Applied Evidence

A patient-centered approach to tapering opioids

J Fam Pract. 2019 December;68(10):548-556

Author(s):

Bennet Davis, MD

Cela Archambault, PhD

Kathy Davis, ANP

Christine R. Oagley, OTR/L, LAc, SEP

Jennifer Schneider, MD, PhD

Amy Kennedy, PharmD

Dan Wilensky, MD

Simply treating opioid addiction isn’t enough. Instead, reposition your patient’s singular circumstances and needs at the center of efforts to end use of these agents.

PDF Download

PRACTICE RECOMMENDATIONS

› Screen for developmental and adult trauma, for current trauma symptoms, and for opioid use disorder before tapering an opioid. B

› Refer the patient for in-depth behavioral health evaluation when screening identifies risk of behavioral problems, to identify psychological, behavioral, emotional, cognitive, and social factors pertinent to the prevention, treatment, or management of physical health problems, such as chronic pain. A

› Refer the patient for addiction medicine treatment, either within your practice or to an outside consultant, when screening for opioid use disorder indicates that the patient is at risk. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Centers for Disease Control and Prevention. Pocket guide: tapering for chronic pain. https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf. Accessed November 25, 2019.

2. Kral LA, Jackson K, Uritsky TJ. A practical guide to tapering opioids. Ment Health Clin. 2015;5:102-108.

3. Murphy L, Babaei-Rad R, Buna D, et al. Guidance on opioid tapering in the context of chronic pain: evidence, practical advice and frequently asked questions. Can Pharm J (Ott). 2018;151:114-120.

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. 2005;90:828-842.

5. Davis M. Prescription opioid use among adults with mental health disorders in the United States. J Am Board Fam Med. 2017;30:407-417.

6. US Government Accountability Office. Report to Congressional Requestors. Prescription drug control: DEA has enhanced efforts to combat diversion, but could better assess and report program results. August 2011. www.gao.gov/assets/520/511464.pdf. Accessed November 25, 2019.

7. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Annual surveillance report of drug-related risks and outcomes. United States, 2017. www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed November 25, 2019.

8. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999-2016, NCHS Data Brief No. 294. December 21, 2017. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/products/databriefs/db294.htm. Accessed November 25, 2019.

9. Overdose death rates. Bethesda, MD: National Institute on Drug Abuse. January 2019. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed November 25, 2019.

10. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2017. NCHS Data Brief No. 329. November 2018. Hyattsville, MD: National Center for Health Statistics. www.cdc.gov/nchs/data/databriefs/db329-h.pdf . Accessed November 25, 2019.

11. Manhapra A, Kertesz S, Oliva A, et al. VA data about Rx opioids and overdose and suicide: clinical implications. Presented at the 2018 National Rx Drug Abuse and Heroin Summit, Atlanta Georgia, April 4, 2018.

12. Demidenko M, Dobscha SK, Morasco BJ, et al. Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. Gen Hosp Psychiatry. 2017;47:29-35.

13. Von Korff M, Walker RL, Saunders K, et al. Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives. Int J Drug Policy. 2017;46:90-98.

14. United States Food and Drug Administration. FDA Drug Safety Communication: FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 9, 2019. www.fda.gov/Drugs/DrugSafety/ucm635038.htm. Accessed November 25, 2019.

15. Becker W, Sullivan LE, Tetrault JM, et al. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2008;94:38-47.

16. Yovell Y, Bar G, Mashiah M, et al. Ultra-low-dose buprenorphine as a time-limited treatment for severe suicidal ideation: a randomized controlled trial. Am J Psychiatry. 2016;173:491-498.

17. Pradhan AA, Befort K, Nozaki C, et al. The delta opioid receptor: an evolving target for the treatment of brain disorders. Trends Pharmacol Sci. 2011;32:581-590.

18. Sugiyama A, Yamada M, Saitoh A, et al. Administration of a delta opioid receptor agonist KNT-127 to the basolateral amygdala has robust anxiolytic-like effects in rats. Psychopharmacology (Berl). 2018;235:2947-2955.

19. Richards EM, Mathews DC, Luckenbaugh DA, et al. A randomized, placebo-controlled pilot trial of the delta opioid receptor agonist AZD2327 in anxious depression. Psychopharmacology (Berl). 2016;233:1119-1130.

20. Yang PP, Yeh GC, Yeh TK, et al. Activation of delta-opioid receptor contributes to the antinociceptive effect of oxycodone in mice. Pharmacol Res. 2016;111:867-876.

21. America’s mental health 2018. Stamford, CT: Cohen Veterans Network. October 10, 2018. https://www.cohenveteransnetwork.org/wp-content/uploads/2018/10/Research-Summary-10-10-2018.pdf. Accessed November 25, 2019.

22. Classification of Chronic Pain, Second Edition (Revised). Washington, DC: International Association for the Study of Pain. Updated 2012. www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673. Accessed November 25, 2019.

23. Davis B, Vanderah TW. A new paradigm for pain? J Fam Pract. 2016 65:598-605.

24. Defrin R, Ginzburg K, Solomon Z, et al. Quantitative testing of pain perception in subjects with PTSD—implications for the mechanism of the coexistence between PTSD and chronic pain. Pain. 2008;138:450-459.

25. Foa EB, Gillihan SJ, Bryant RA. Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: lessons learned from prolonged exposure therapy for PTSD. Psychol Science Public Interest. 2013;14:65-111.

26. Miele D, O’Brien EJ. Underdiagnosis of posttraumatic stress disorder in at risk youth. J Trauma Stress. 2010;23:591-598.

27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Publishing; 2013:541.

28. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372:241-248.

29. Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. 2017;318:425-426.

30. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. 2001. www.naabt.org/documents/APS_consensus_document.pdf. Accessed November 25, 2019.

31. Fishbain DA, Cole B, Lewis J, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9:444-459.

32. Volkow ND, McClellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374:1253-1263.

33. Treede RD, Rief W, Barke A. A classification of chronic pain for ICD-11. Pain. 2015;156:1003-1007.

34. Screening, brief intervention, and referral to treatment (SBIRT). Rockville, MD: Substance Abuse and Mental Health Services Administration. www.samhsa.gov/sbirt. Accessed November 25, 2019.

35. Schneider JP, Davis B. How well do you know your patient? Pract Pain Manag. 2017;17(2). www.practicalpainmanagement.com/resources/practice-management/how-well-do-you-know-your-patient. Accessed November 25, 2019.

36. Schneider JP. A patient-centered approach to the opioid overdose crisis. J Miss State Med Assoc. 2018;59:232-233.

Many Americans who are treated with prescription opioid analgesics would be better off with less opioid or none at all. To that end, published opioid prescribing guidelines do provide guidance on the mechanics of tapering patients off opioids^1-4—but they have a major flaw: They do not adequately account for the fact that people who have a diagnosis of chronic pain are a heterogeneous group and require diagnosis-specific treatment planning. A patient-centered approach to opioid tapers must account for the reality that many people who are given a prescription for an opioid to treat pain have significant mental health conditions—for which opioids act as a psychotropic agent. An opioid taper must therefore address psychological trauma, in particular.⁵ (See “Tapering and harm-reduction strategies have failed.”^6-14)

SIDEBAR
Tapering and harm-reduction strategies have failed

Efforts to address the rising number of overdose events that involve opioids began in earnest in 2010. In a 2011 Government Accountability Office report to Congress, the Drug Enforcement Agency reported that “the number of regulatory investigations (of medical providers who prescribed opioids) tripled between fiscal years 2009- 2010.”⁶

How has it gone since 2010? High-dosage prescribing of opioids has fallen by 48% since 2011, yet the decline has not reduced overdose events of any kind.^7,8 Just the opposite: The 19,000 overdose deaths recorded in 2010 involving any opioid increased to 49,068 by 2017, the National Institute on Drug Abuse reports.⁹ The increase in opioid overdose deaths is fueled by a recent 9-fold increase in consumption of the synthetic opioid fentanyl: “The rate of drug overdose deaths involving synthetic opioids other than methadone … increased on average by 8% per year from 1999 through 2013 and by 71% per year from 2013 through 2017.”¹⁰

These and other statistics document only a modest rise in deaths that involve prescription opioids: from 15,000 in 2010 to 19,000 in 2016.9,10 Since 2010, the crisis of opioid overdose deaths burns hotter, and the pattern of opioid use has shifted from prescription drugs to much deadlier illicit drugs, such as heroin.

Interventions have not been successful overall. Results of research focused on the impact of opioid tapering and harm-reduction strategies implemented this decade are likewise discouraging. In 2018, the US Department of Veterans Affairs reported that opioid discontinuation was not associated with a reduction in overdose but was associated with an increase in suicide.^11,12 Von Korff and colleagues, in a 2017 report, concluded that “Long-term implementation of opioid dose and risk reduction initiatives [in Washington state] was not associated with lower rates of prescription opioid use disorder among prevalent [chronic opioid therapy] patients.”¹³

Evidence suggests that efforts to address the opioid crisis of the past decade have had an effect that is the opposite of what was intended. The federal government recognized this in April 2019 in a Drug Safety Communication: “The US Food and Drug Administration (FDA) has received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”¹⁴

In this article, we present an evidence-based consensus approach to opioid tapering for your practice that is informed by a broader understanding of why patients take prescription opioids and why they, occasionally, switch to illicit drugs when their prescription is tapered. This consensus approach is based on the experience of the authors, members of the pain faculty of Project ECHO (Extension for Community Healthcare Outcomes) of the ECHO Institute, a worldwide initiative that uses adult learning techniques and interactive video technology to connect community providers with specialists at centers of excellence in regular real-time collaborative sessions. We are variously experts in pain medicine, primary care, psychology, addiction medicine, pharmacy, behavioral health therapy, occupational medicine, and Chinese medicine.

Why Americans obtain prescription opioids

There are 4 principal reasons why patients obtain prescription opioids, beyond indicated analgesic uses:

1. Patients seek the antianxiety and antidepressant effects of opioids. Multiple converging lines of evidence suggest that antianxiety and antidepressant effects of opioids are a significant reason that patients in the United States persist in requesting prescriptions for opioids:

In our experience with more than 500 primary care telemedicine case presentations, at least 50% of patients say that the main effect of opioids prescribed for them is “it makes me feel calm” or “more relaxed.”
In a 2007 survey of 91,823 US residents older than 18 years, nonmedical use of opioids was statistically associated with panic, social anxiety, and depressive symptoms.¹⁵
Ten years later, Von Korff and colleagues found that more than half of opioid prescriptions written in the United States were for the small percentage of patients who have a diagnosis of serious anxiety or depression.¹³
In 2016, Yovell and colleagues reported that ultra-low-dosage buprenorphine markedly reduced suicidal ideation over 4 weeks in 62 patients with varied levels of depression.¹⁶

There is also mechanistic evidence that the antianxiety and antidepressant effects of opioids are significant reasons Americans persist in requesting prescription opioids. The literature suggests that opioid receptors play a role in mood regulation, including alleviation of depression and anxiety; recent research suggests that oxycodone might be a unique mood-altering drug compared to other common prescription opioids because of its ability to affect mood through the δ opioid receptor.^17-20

It should not be a surprise that Americans often turn to opioids to address posttraumatic stress disorder (PTSD), anxiety, and depression. A recent study of the state of the US mental health system concluded that mental health services in the United States are inadequate—despite evidence that > 50% of Americans seek, or consider seeking, treatment for mental health problems for themselves or others.²¹

2. Patients experience pain unrelated to tissue damage. Rather, they are in pain “for psychological reasons.”²² In 2016, Davis and Vanderah wrote: “We theorize that a functional change in the [central nervous system] can occur in response to certain emotional states or traumatic experiences (eg, child abuse, assault, accidents).” They connect this change to central sensitization and a reduced pain-perception threshold,²³ and strongly suspect that many patients with chronic pain have undiagnosed and untreated psychological trauma that has changed the way their central nervous system processes sensory stimuli. The authors call this “trauma-induced hyperalgesia.”

Continue to: Psychological trauma...