Tapering Strategies for Patients on Long Term Opioid Therapy

LTOT

Disclosures:

• Ruben Halpern, Roger Chou, Mark Stephens,

Jim Shames, Andrew Suchocki, Laura Heesacker,

Simon Parker-Shames, Tim Gallagher, Jane Lincoln,

Nadejda Razi Robertson, Jane Ballantyne,

Paul Coelho: None

• Anna Lembke: Plaintiff in Pharma Litigation

• Andrew Kolodny: Plaintiff in Pharma Litigation

Off Label Recommendations:

• Buprenorphine to be used for the treatment of Opioid Dependence when tapering is unsuccessful.

Today’s Panel:

• Andrew Suchocki, MD, MPH, Medical Director, Clackamas Health Ctrs

• Jane Ballantyne, MD: UW School of Medicine

• Paul Coelho, MD: Pain Management, Salem Oregon

• Jim Shames, MD: Jackson Co PH and OHA/Synergy Consultant

Pros for reducing opioid dose

• Way too many pills in circulation• Clearly much of what we are

prescribing is being diverted

• We need to turn down the spigot

• High dose opioids carry significant risks

• Opioids may not be providing much pain relief once dependence has occurred.

Cons for reducing opioid dose

• Some folks are stable on their current regime. • “If it ain’t broke don’t fix it”

• There is trauma associated with tapering, and some risk, especially if done rapidly

The Problem: Our understanding in 2019

• Liberal opioid prescribing in the past has led to large numbers of individuals on LTOT for chronic pain

There is a consensus exemplified by CDC guidelines:

• It is generally unsafe and inappropriate for sustained opioid doses >50 MME.

The Taper Dilemma: Decreasing high dose opioids….

• Safest for patients•Produces anxiety for

patient and prescriber•May create pain in

short term if rapid.•Can create stigma,

animosity, and risk of suicide

What does current science tell us about the effectiveness of COT?• SPACE trial: JAMA 2018…”Treatment with opioids was not

superior to treatment with nonopioid medications for improving pain-related function over 12 months.”

• Structured Evidence-Based Systematic Review: Journal of Pain Medicine, December 2018….”80% of CPPs had improved pain after taper.”*

• *Hypothesis: Objective: To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.

• Review of 20 studies fulfilling criteria

• Review of 2199 Chronic Pain Patients tapered off opioids

• 100% supported the hypothesis.

• 80% had improved pain after taper

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-Patients are scared-Doctors are scared-Some patients are harmed

Pushback!

NEJM : Deborah Dowell, M.D., M.P.H., Tamara Haegerich, Ph.D., Roger Chou, M.D.

• ”No Shortcuts to Safer Opioid Prescribing”

• “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations …include inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice.”

• “misapplication of the recommendations to populations outside the scope of the guideline”

• “reports of misapplication of the guideline’s dosage thresholds to opioid agonists for treatment of opioid use disorder.”

• “we know little about the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them.”

Who is Working on this issue?

OPG tapering guideline Workgroup

• Anna Lembke: Stanford• Mark Stephens: Consultant • Jim Shames: Jackson County• Roger Chou: OHSU• Paul Coelho: Salem Health• Rubin Halpern: Providence Portland• Jane Ballantyne: UW• David Tauben: UW• Andrew Kolodny: Brandeis• And others brought in to provide advice and consent

Oregon Opioid Tapering Taskforce

• Experts from many different disciplines

• To provide guidance to the OHA

• Create “best practice” for tapering

• Benefits of Opioid Therapy:

• Improved quality of life

• Improved function

• Improved pain relief (genuine pain relief due to opioids).

Risks:• OUD or Opioid Dependency• Risk of overdose rises as the dose increases. • Exacerbating mental health or physical conditions• Opioid adverse effects

Assessment and management of the patient using standardized tools:• Query of the PDMP

• UDS (Urine Drug Screening)

• Obtaining Previous Records and interview family members.

• Assess substance use and mental health disorders

• Assessment of pulmonary and other chronic health problems

• Screening for Fibromyalgia, Catastrophizing

• Concurrent use of sedative hypnotics

• Informed consent

• Create clinic-wide systems: regular visits, controlled substance registry, incorporate the above screening into policy

Making the Risk/Benefit decision: To taper or not? • The decision is based primarily upon safety. This should be patient

centered but provider driven.

• Review the patient assessment to determine if the benefits of COT outweigh the risks.

• We want the patient to be successful, and safe.

There is no need to hurry this process if there is

not an immediate risk present.

• Complex Persistent Opioid Dependence (CPOD)

• Complex: Dependence is complicated by desire to continue taking opioid for the treatment of pain. Withdrawal is complicated by anhedonia and hyperalgesia which, unlike classic ‘physical’ symptoms, may not reverse within days.

• Persistent: Tapering is poorly tolerated. Tapering, therefore, may fail, or is highly protracted (takes months or years).

• What distinguishes CPOD from OUD: • No craving

• No compulsive use

• No harmful use that is not medically directed (patient takes opioid exactly as prescribed)

• Social disruption is attributed to pain and not to OUD

Questions for the Panel