Centering the patient in decisions about opioid tapering

KEYWORDS:

• Opioids
• tapering
• dose reduction
• harms
• patient-doctor communication

1.

As a medical student in San Francisco in the 1990s, I felt fortunate to receive cutting-edge instruction from an attending physician regarding the optimal and safest approach to chronic pain management. I was taught that, for most patients with chronic pain, opioids were safer than alternative drugs, and that if pain was not well-controlled on a lower opioid dose, then the dose could be increased without limit based on patient tolerance. I was also taught that longer-acting opioids were preferred, because they prevent rebounds in the ‘pain cycle,’ so I typically switched patients to long-acting opioids along with short-acting opioids for breakthrough pain.

We now know that this ‘evidence-based’ instruction was scripted by drug manufacturers who capitalized on massive untapped markets of patients with chronic pain [1]. Meanwhile, physicians and regulators failed to demand better evidence of effectiveness and safety before adopting opioids as a primary modality for chronic pain treatment. All of this lay at the roots of the ongoing opioid overdose epidemic, which is now sustained by high rates of illicit fentanyl overdose [2], even as opioid prescribing rates have declined [3].

Many clinicians have experienced a sense of bafflement as the pendulum in opioid prescribing has swung to and fro. We are now in a ‘post-tapering’ phase where most clinicians see that the promise of opioids was oversold, and many patients previously prescribed higher dose opioids have had doses tapered, often involuntarily. Yet most primary care and pain clinicians continue to care for many patients who remain on long-term opioids and must address whether patients should now be tapered and how to incorporate patient values and perspectives in decision-making around in tapering. Based on current evidence and my clinical experience, I argue that patients should remain at the center of most opioid tapering decisions due to the competing risks of continuation vs. tapering and uncertainties about accompanying benefits.

At the outset, clinicians must delineate decisions about opioid continuation from decisions about opioid initiation. We now know from multiple trials that initiation of opioids is typically not more effective than non-opioids for the treatment of common causes of chronic pain [4]. Meanwhile, the risks of long-term opioids include risks of overdose, addiction, depression, sexual dysfunction, all-cause mortality, and other side effects [5]. Hence, Centers for Disease Control and Prevention (CDC) guidelines advise that non-opioids should be preferred for most patients with chronic pain, and that if opioids are initiated, clinicians should prescribe the lowest possible dose [5].

However, patients and clinicians face a more vexing decision after opioids have been initiated and the patient has been taking them long-term. For such patients, opioid continuation confers the risks noted above, yet observational studies have consistently shown associations between opioid tapering or discontinuation and risks of overdose, withdrawal, or mental health crisis, including suicide [6–15]. Opioid tapering, particularly at faster rates, may precipitate withdrawal which may prompt patients to use illicit or diverted opioids. If tolerance abates after tapering, exposure to illicit or diverted opioids may lead to overdose. The FDA has warned [16], and observational evidence confirms, that rapid tapering likely augments risk of depression and suicidal crisis [6,9].

An evidence-based approach, therefore, would require that most clinical decisions around tapering should grapple with the competing risks of opioid continuation vs. tapering. The CDC highlights situations wherein opioid tapering is clearly indicated, such as patients with evident toxicity (e.g. slurred speech) [5]. Health and Human Services (HHS) guidelines for opioid tapering and others have also highlighted the challenges of working with opioid-prescribed patients who exhibit opioid misuse or possible opioid use disorder [17,18]. However, for patients who have not exhibited opioid misuse, the bioethical principle of autonomy implies that the patient should be at the center of the decision about continuation vs. tapering, and that it is the clinician’s responsibility to inform them about the competing risks and engage them in making a decision that is aligned with their goals and preferences.

Patient-centered, informed decision-making is easy to call for but difficult to achieve in practice. Ideally, these conversations would occur in the context of a longitudinal, trustful relationship. Longitudinal, continuous relationships are an essential concept of primary care, but this ideal is increasingly elusive as patients frequently change primary care physicians due to insurance coverage or market forces. Due to medical and psychosocial complexity, patients prescribed long-term opioids may have even greater difficulty establishing trustful, longitudinal relationships with prescribers, and discussions around tapering may heighten patient anxiety and mistrust. Indeed, research suggests opioid tapering may be associated with disruption of patient-provider relationships [6,19].

Clinicians must therefore set the stage for conversations around tapering by affirming a commitment to the patient’s health and wellbeing and a desire to serve the patient whether they decide to continue or taper opioids. After affirming a commitment to the patient-clinician relationship, clinicians should then elucidate the competing risks of opioid continuation vs. tapering, along with the potential balance of benefits associated with each alternative. Some patients may perceive substantial benefits from opioid therapy in terms of pain and function, while others may articulate a goal of reducing or discontinuing opioids. If patients wish to continue opioids after receiving information regarding known risks of continuation vs. tapering, clinicians should support them in this choice, while mitigating risks of overdose by minimizing exposure to other sedating medications, providing education regarding opioid safety, and prescribing naloxone. If patients wish to pursue tapering, the CDC and HHS have developed guidelines to plan for safe opioid dose reduction, often via gradual dose reduction over many weeks to months [5,17]. In some settings, clinical pharmacists may provide valuable support in developing and implementing a tapering plan. Given the risks of mental health crisis, clinicians should alert patients regarding the risk of depressive or anxiety symptoms during tapering and arrange regular follow-up for ongoing assessment and support.

At a societal level, the opioid overdose crisis has been terrifying. Like all members of society, clinicians have been frightened by the rapid rise and tragic frequency of overdose deaths. It may still seem urgent and imperative for clinicians to reduce opioid prescribing and discontinue long-term opioids, and policies and guidelines have encouraged and incentivized dose tapering. Yet the current wave of opioid overdose mortality is being driven predominately by illicit fentanyl use rather than opioid prescribing [20]. Meanwhile, opioid tapering poses its own serious risks to patients. For most patients prescribed long-term opioids, clinicians should take the time to guide patients toward an individualized decision about whether to continue or taper opioids and ensure that the decision to taper is aligned with the patient’s values, goals, and preferences.

Disclosure of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

This paper was not funded.