Tapering Long-Term Opioid Therapy...Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH April 28, 2017 / CSAM – Treang Addic4on in the Primary Care Safety Net (TAPC) Webinar

Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH

April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries

TaperingLong-TermOpioidTherapyJosephW.Frank,MD,MPH

VAEasternColoradoHealthCareSystemUniversityofColoradoSchoolofMedicine

CSAMWebinar,April28,2017

Disclosures/ConflictsofInterest

Thespeakersandplannersofthiswebinarhavenorelevantfinancialrela4onshipstodisclose.



SessionOverview

•  Theevidence•  Theguidelines•  Theprocessofopioiddosereduc4on

Case

•  52-year-oldmanwithchroniclowbackpainforthepast11yearsfollowingworkinjury,ondailyopioidtherapyfor9years

•  Presen4ngtodaytoanewprimarycareprovidera[erpriorPCPre4red•  Currentlyonlong-ac4ngmorphine90mg3XD&short-ac4ngoxycodone20mg4XDPRN

•  Ibuprofen,naproxen,topicalsnoteffec4veonpriortrials•  Walksthedogseveral4mesweekly,par4cipatedinPT2yearsago



Ini4a4onofopioids

Con4nua4on,monitoring&riskmi4ga4on

3-6months Months-Years

Tapering&discon4nua4on

Weeks-Months-Years

PhaseofLTOT

Dura/on

Risks&benefits

??? Benefits>>>Risks Risks>>>Benefits

Mul4disciplinary,mul4modalpaincare

Non-opioidpaincare

THEEVIDENCE



Ques4on

From1-10,howdifficultisyourtypicalconversa4onwhenrecommending&implemen4ngopioiddosereduc4on?

Pa/ents(N=24)•  Barriers

– Lowperceivedriskofoverdose

– Pessimismre:non-opioidtherapies

– Prioropioidwithdrawalsymptoms

Frank et al. Pain Med 2016; Kennedy et al. 2017 Under review

Opioidtaperingischallenging



AddquotesPa4ent:“Idon’tthinkpeopleinchronicpainthinkaboutlongterm.Wearebasically,howdoIgetthroughtoday?Ijustgo>agetthroughtoday.”

Pa4ent:“Ihadtakenibuprofen,Aleve,everythingoverthecounter,anditdidnothingtohelpmeatall.SoIknewIneededmorehelp,strongerhelp.”

WithdrawalquotePa4ent:“Idon’tthink[doctors]areawareofhowbadwithdrawalsare.Imeanthere’svomiFngbile.There’sstomachcramps,there’sthecoldshakesandfever...Imean,it’spre>ybad.”



Pa/ents(N=24)•  Barriers

– Lowperceivedriskofoverdose

– Pessimismre:non-opioidtherapies

– Prioropioidwithdrawalsymptoms

Frank et al. Pain Med 2016; Kennedy et al. 2017 Under review

Primarycareproviders(N=40)•  Barriers

– Emo4onalnatureofdiscussion

–  Inadequatetraining&resources

– Lackoftrustbetweenpa4ent&provider

Opioidtaperingischallenging

PCP:“Amajorissue…isFmeandresources.And,there’snowayyoucanconsistentlyput20poundsofpotatoesinafivepoundbag…IthinkeveryonearoundthetableisveryconscienFous,veryawareoftherisks.It’sama>erofresources,Fme,thatisnotallocated,andthat’sthenatureofmedicinetoday,andit’sthenatureofprimarycare.”



Dose-dependentrisksofopioid-relatedharms

0

1

2

3

4

5

6

7

8

9

10

<19mg/day

20-49mg/day

50-99mg/day

>=100mg/day

RiskRa/

o Dunn2010

Bohnert2011

Gomes2011

Gomes2013

Zedler2014

Dunn et al. Ann Int Med 2010; Bohnert et al. JAMA 2011; Gomes et al. Arch Int Med 2011; Gomes et al. JAMA Int Med 2013; Zedler et al. Pain Med 2014

•  Riskofopioid-relatedharmsassociatedwithhighopioiddose

•  Dosereduc4onmaydecreaserisk

•  Lipleevidenceonbenefits&risksofopioidtapering

Risks&benefitsoftapering?

•  Twopublishedsystema4creviewsincluded5smallrandomizedtrialsofopioidtaperinginterven4ons–  Noconclusionsdrawn

•  Oursystema4creviewincluded62controlledanduncontrolledstudies– Mul4disciplinaryinterven4onsappeareffec4ve

•  Fewstudiesinprimarycareserngs

–  ‘Verylow’qualityevidencesugges4ngbenefitsonpainandfunc4on•  Fewstudiesassessedinvoluntarytaperingorriskofsubsequentsubstanceuseoradverseevents

Chou et al Annals 2015; Windmill et al. Cochrane Review 2013; Frank et al. 2017 Under review



•  Short-termrisks:–  Opioidwithdrawalsymptoms,increasedpain,andlosstofollow-up

•  Long-termissues:–  Relapse,func4onandmedicolegalimplica4ons

•  “Aplanthatanindividualpa4entcanembracewithasignificantdegreeofpersonalengagementmightbemoreimportantthanfollowingaspecificprotocol”

Berna et al. Mayo Clin Proc 2015

Risks&benefitsoftapering?

THEGUIDELINES



Dowell et al. JAMA 2016

•  #2:Beforestar4ng,considerhowopioidswillbediscon4nued•  #5:Carefullyreassessrisks&benefitswhenconsideringdoseincreases≥50mgMEDD&avoiddoseincreases≥90mgMEDD

•  #7:Ifbenefitsdonotoutweighharms,op4mizeothertherapies&workwithpa4entstotaperand/ordiscon4nue

•  #12:Offerorarrangeevidence-basedtreatmentforpa4entswithopioidusedisorder

•  Recommendsagainstdoses>90mgMEDDforchronicpain•  Recommendsevalua4onfortaperingforpa4entstaking>90mgMEDD

•  Recommendsevalua4onofrisksandbenefitsofcon4nuingLTOTalongwithrisksandbenefitsoftaperingLTOT



•  Suggeststaperingopioidtothelowestpossibledose,includingdiscon4nua4on,forpa4entsusing≥90mgMEDDwithpersistent,problema4cpainorsideeffects– Weakrecommenda4on:Providersshouldindividualizetogoals,values&preferencesofpa4ents

http://nationalpaincentre.mcmaster.ca/documents/Opioids%20guideline%20English_30Jan2017_correctnumbering.pdf

THEPROCESSOFOPIOIDTAPERING



PreparingforEndattheBeginning

•  Op4mizenon-pharmacologic&non-opioidpharmacologictherapiesforchronicpain

•  Establishrealis4ctreatmentgoalsforpain&func4on•  Discussrisks,especiallyhigh-dosetherapy•  Considerhowopioidtherapywillbediscon4nuedifbenefitsdonotoutweighrisks•  Responsetoaberrantbehaviors•  Treatmentofopioidusedisorder


•  Atini4a4on,doctorsdidnottalkabout:– Non-opioidtreatmentop4ons 32%– Addic4on&dependence 28%

– Possiblesideeffects 23%– Planfordiscon4nuing 60%

http://apps.washingtonpost.com/g/page/politics/washington-post-kaiser-family-foundation-long-term-opioid-users-poll/2142/



Discuss,Ask&Educate

Discuss•  Listentopa4ent’sstory

•  Validatepain•  Involvesocialsupport

VA PBM Academic Detailing Service. Opioid Tapering Decision Tool. www.pbm.va.gov

Educate•  Biopsychosocialmodel

•  Non-opioidtreatments

•  Taperplanning

Ask•  Func4onalgoals•  Sideeffects•  Priorexperiencewithtapering

•  Importanceoftapering– Confidence– Readiness

Ambivalenceinlong-termopioidtherapy

•  Amongadultsonmoderate-highdoseLTOT(≥50mgMEDD),

– 93%reportedopioidsatleastmoderatelyhelpful

– 42%reportedsideeffectsasatleastmoderatelybothersome

– 49%reportedadesiretocutdownorstop

Thielke et al. Clin J Pain 2013



Ques4on

Inyourexperience,whatpropor4onofopioidtapershavebeenclinician-ini4atedratherthanpa4ent-ini4ated?A.  0%(i.e.,allpa4ent-ini4ated)B.  ~25%C.  ~50%D.  ~75%E.  100%(i.e.,allclinician-ini4ated)



Indica4onsforOpioidTapering1.  Pa4entpreference2.  Benefits

–  Lackofmeaningfulfunc4onalimprovement

–  Improvementinunderlyingpaincondi4on

–  Paincondi4onnotopioid-responsive

3.  Risks/Harms

–  Unmanageablesideeffects

–  Concurrenthigh-riskmedica4ons(e.g.,benzos)

–  Comorbidi4es–  Concernforopioidusedisorder–  Non-adherencetoriskmi4ga4onstrategies

–  Inadequatepar4cipa4onincomprehensivepaincareplan

–  High-dosetherapy4.  Diversion

VA/DoD 2017 Clinical Practice Guideline

PCP:“SomeoneneedstocomeoffbecauseofdualdippingormaybetheycameupwithaposiFveUDSorsomethinglikethat,sothosearethesomewhateasyones.”

PCP:“YoufindoutonthePDMPthatthepersonisgeTngstufffromotherpeople.That’saveryeasytaper‘causeyoujustsay,‘You’redone.’”



Case

•  Atyoursecondvisit,yourpa4entreportsthathisleveloffunc4onhasdeclinedsubstan4allyinthepastyear.Hislong-ac4ngmedica4onishelpfulbutlasts3-4hours.Henotesfrequentbutmanageablecons4pa4on.

•  Hiswifejoinshimtoday.Sheexpressesconcernabouthisfrequentday4menapping&tellsyouthathehadaminorcaraccidentlastweek.

•  Hedidnotcompleteaurinedrugscreenbutagreestodosotoday.•  HemissedaPhysicalTherapyappointmentlastweek.



Ques4on

Yourecommendwhichofthefollowing?A.  IncreaseMSSRto4XDB.  Con4nuecurrentmedica4onsC.  BeginslowtaperwithnextfillD.  Rapiddiscon4nua4ond/tadverseevent

UnilateralDecision-Making

SharedDecision-Making

PCP:“It’smylicensethat’sonthelineforthissoIulFmatelydogettochoose.

Obviously,Idowanttodoshareddecision-making.Absolutely.ButifapaFentsnot,

youknow…It’sonmeulFmately.”



PCP:“’Iamuncomfortableprescribingthathighofadose’couldbeperceivedas‘Well,whatcouldIsaytomakeyoucomfortable?Imean,youknow,it’sbeenworkingforme’.ItbecomesaYouvs.MeconversaFon”

PCP:“Youseethepersononyourscheduleandyouknowit’sgoingtobe…oneofthosejustdrainingconversaFons.”

Pa4ent:“IhaveatremendousfearinadoctorsayingIwantyoutotaperoffthemethadoneandgettotallyoffthemethadonewithnoalternaFvewhatsoever.”

Pa4ent:“Ialsohadlotsoffearsabout,let’ssaytherewasanapocalypseinoursociety…Whatwouldhappentome?WherewouldIgetmymedicaFonfrom?Whatwasgoingtohappen?”



VA/DoD 2017 Clinical Practice Guideline

ModuleC:TaperingorDiscon4nua4onofOpioidTherapy




Decision-MakingDuringOpioidTapering

•  Goals•  Timingofini4a4on•  Speed•  Medica4onorder•  Painmanagement•  Opioidwithdrawalmanagement•  Comorbiditymanagement•  Educa4on


Sideeffects?

Func4onalgoals?

Opioidwithdrawal?

Dose?

Discon4nua4on?




•  Goals•  Timingofini/a/on•  Speed•  Medica4onorder•  Painmanagement•  Opioidwithdrawalmanagement•  Comorbiditymanagement•  Educa4on

Today?

Nextrefill?

Pa4ent-driven?



CDC2016:•  10%perweek•  10%permonthiflong-termVA/DoD2017:

•  5-20%per28days





•  Randomizedcontrolledtrialof22-weekopioidtapersupportinterven4on– WeeklyvisitswithPA– Mo4va4onalInterviewing– Self-managementtraining

Sullivan et al. J Pain 2017.

%reduc/on@22weeks

Interven/on(N=18)

UsualCare(N=17)

0% 4(22%) 8(47%)

1-49% 6(33%) 5(29%)

50-99% 7(39%) 2(12%)

100% 1(6%) 1(6%)

•  CohortstudyofVeteransundergoingvoluntaryopioiddosereduc4on(N=50)

•  Averagedosedecreasedby46%over12months– Discon4nua4oninonly6pa4ents– Dosereduc4on“paused”foratleast3monthsin25pa4ents– Dose“readjustedhigher”in6pa4ents

Harden et al. Pain Medicine 2015.






•  Goals•  Timingofini4a4on•  Speed•  Medica/onorder•  Painmanagement•  Opioidwithdrawalmanagement•  Comorbiditymanagement•  Educa4on

Long-ac4ng

vs.

Short-ac4ng




•  Goals•  Timingofini4a4on•  Speed•  Medica/onorder•  Painmanagement•  Opioidwithdrawalmanagement•  Comorbiditymanagement•  Educa4on

Samplewripeninstruc4ons



•  NSAIDs•  APAP•  Topicals•  TCAs•  Injec4ons•  CBT•  MBSR•  Massage•  Acupuncture•  Exercise•  Aquatherapy•  Physical

Therapy

•  Occupa4onalTherapy

•  Spinalmanipula4on

•  Yoga•  Taichi•  Heat•  Ice•  TENS•  Autogenic

training•  Relaxa4on•  Biofeedback











MentalHealth

SubstanceUse

Sleep

Weight

Othermedicalcondi4ons


•  Goals•  Timingofini4a4on•  Speed•  Medica4onorder•  Painmanagement•  Opioidwithdrawalmanagement•  Comorbiditymanagement•  Educa/on

Overdoserisk

– Lossoftolerance&naloxone

–  IllicitopioiduseFollow-upplan

– Visitfrequency– Pointofcontact




Case

•  Overthepast6months,yourpa4enthasdecreasedfrom390mgMEDDto120mgMEDD.

•  Heistearfultodayandreportsthathispainlevelhasincreasedinthelastmonth.Hemissedhislastappointmentwithyou.

•  Heranoutofmedica4on1weekago,experiencewithdrawalsymptomsandboughtopioidmedica4onsfromaneighbor.

•  Heacknowledgesalossofcontrolandnega4veconsequencesimpac4nghismarriage.

Ques4on

Yourecommendwhichofthefollowingdosingstrategies?A.  PauseopioidtaperatcurrentdoseB.  Con4nueslowtaperC.  Rapiddiscon4nua4onD.  Switchtobuprenorphine



DSM-VOpioidUseDisorderDiagnosis1. Largeramountsoroveralongerperiodthanintended2. Unsuccessfuleffortstocutdownorcontroluse3. Timespentobtaining,usingorrecovering4. Craving5. Failuretofulfillmajorroleobliga4ons6. Socialorinterpersonalproblems7. Ac4vi4esgivenuporreduced8. Usewhenitisphysicallyhazardous9. Physicalorpsychologicalproblem10. Tolerance*11. Withdrawal*

Mild=2-3Moderate=4-5Severe≥6

Degenhardtetal.LancetPsychiatry2015;2(4):314-322

Obtainingawaiver

•  Buprenorphinetraining– Eighthours,availableinonlineformat– Peer-to-peermentoring

•  CDC:“Incommuni4eswithoutsufficienttreatmentcapacity”,physiciansshould“stronglyconsider”obtainingawaiverfromSAMHSAthatallowsthemtoprescribebuprenorphine




Takehomepoints

•  Adiscussionofopioidtaperingshouldbeginandcon4nueduringlong-termopioidtherapy

•  Opioidtaperingshouldseektoop4mize:

– Benefits&risksofopioidmedica4onsandopioidtapering– Func4onandqualityoflife– Pa4entengagement

•  Thecomplexityofopioidtaperingofferschallengebutalsoopportuni4esforshareddecision-making

Materials•  VA/DoD2017ClinicalPrac4ceGuidelinesontheManagementofOpioidTherapyforChronic

Pain–  hpps://www.healthquality.va.gov/guidelines/pain/cot/index.asp

•  VAOpioidTaperDecisionTool–  hpps://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/

Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf•  VAOpioidSafetyQuickReferenceGuide(2014)

–  hpps://www.va.gov/PAINMANAGEMENT/docs/PainProviderADQuickReferenceGuide508.pdf•  CDCOpioidGuidelineResources

–  hpps://www.cdc.gov/drugoverdose/prescribing/resources.html•  CDCPocketGuideforTaperingOpioidsforChronicPain

–  hpps://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf•  FebruaryCSAMWebinaron‘Psychological/BehavioralStrategiesforPainControl:Toolsfor

PCPstoUseina20MinuteVisit’–  hpps://tapcprogram.files.wordpress.com/2017/03/csam-pain-webinar-resource-list-final.pdf



Ques4ons?

[email protected]

Friday,06/23/2017Friday,07/28/2017Friday,08/18/2017*Friday,09/22/2017

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