Tapering of chronic opioid therapy (CDC, 2022A) Sometimes, clinicians must decide whether to decrease or discontinue chronic opioid therapy. Many factors may contribute to this decision: Individual request; lack of response; signs of substance abuse disorder, overdose, or other serious adverse events; or early signs of overdose risk. Therefore, any tapering schedule must be patient-specific to minimize withdrawal symptoms while maintaining adequate pain management. A general recommendation is to begin with a 10% decrease in the initial weekly dose. Some patients who have taken opioids for a long time may require slower tapers (e.g., 10% per month). Adjust the rate and duration of the taper based on the patient’s response. It is advisable to slow or pause a taper to manage withdrawal symptoms rather than reversing the taper. It is essential to discuss the risk of overdose if a patient quickly returns to a prescribed higher dose. Consider prescribing naloxone to reverse possible overdose symptoms. After achieving the smallest available dose, the interval between opioid doses increases, and opioids stop when taken less than once daily. Individuals at high risk of harm, such as pregnant individuals or those with substance abuse disorder, may require coordination Naloxone for emergent opioid overdose On average, every eight minutes, an individual dies from an opioid overdose (Skolnick, 2018). Individuals at higher risk for acute overdose include those who use prescription opioids, benzodiazepines, and alcohol. Additionally, individuals with substance or mental health use disorders. These factors can affect the entire family, since these individuals may obtain opioids from family members. Children are at risk when an adult in their family ingests opioids at home. Individuals with lower tolerance due to incarceration, detoxification, or other controlled settings are also at higher risk for acute opioid overdose. Physiological damage can occur after four minutes, and death can occur in four to six minutes. Signs and symptoms of acute opioid overdose include: ● Unusual sleepiness or unresponsiveness. (SAMHSA) oversees the accreditation and standards for opioid treatment programs (OTP). Many medication-assisted treatments (MAT) for opioid addiction are regulated under the CSA (SAMHSA, 2022a). The Drug Addiction Treatment Act of 2000 (DATA 2000 ACT) permitted physicians who met set qualifications to manage opioid dependency with FDA-approved medications, such as buprenorphine, in treatment settings other than OTPs (see Table 9). The DATA 2000 Act allowed physicians to obtain a waiver (i.e., DEA-X) to treat opioid use disorder with Schedules III, IV, and V medications (such as buprenorphine alone or in combination with other medications) that the FDA has approved for this indication (SAMHSA, 2022b). Qualified practitioners could offer buprenorphine, a medication approved by the Food and Drug Administration (FDA) to treat opioid use disorders (OUD). In addition, the Drug Addiction Treatment Act of 2000 (DATA 2000) and the Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities or SUPPORT for Patients and Communities Act of 2018 (SUPPORT Act) expanded the use of medication- assisted treatment using buprenorphine to additional practitioners in various settings (SAMHSA, 2022c). Qualified practitioners included physicians, nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs),
with treatment experts. Withdrawal symptoms are especially concerning in pregnant patients due to the risks to the pregnant individual and the fetus. It is crucial to ensure patients receive appropriate encouragement and psychosocial support, including consultations with mental health providers and treatment for opioid use disorder as needed. Reassure individuals that most have improved function, without worse pain, after tapering opioids. In addition, some patients experience less pain after a taper, even though the pain may worsen initially. Self-Assessment Quiz Question #5 Any tapering schedule must be patient-specific to minimize withdrawal symptoms. The CDC recommends what percentage while maintaining adequate pain management?
a. 10% decrease of the initial dose per week. b. 15% decrease of the initial dose per week. c. 25% decrease of the initial dose per week. d. 45% decrease of the initial dose per week.
● Decreased or absent breathing. ● Slow heartbeat or low blood pressure. ● Skin feeling cold and clammy. ● Pinpoint pupils. ● Dusky nails and lips.
Naloxone hydrochloride is an opioid antagonist which blocks opiate receptors in the brain and other parts of the body (Drugs. com, 2023). By occupying the receptor and blocking the action of the opioid, effects of naloxone reverse opioid effects by competing for opioid sites in the central nervous system, with a great affinity for the µ receptor (Drugs.com, 2023). Naloxone nasal inhalation kits are widely accepted for opioid reversal in emergent situations (Skolnick, 2018). certified registered nurse anesthetists (CRNAs), and certified nurse-midwives (CNMs). To receive a practitioner waiver to administer, dispense, and prescribe buprenorphine, practitioners had to notify SAMHSA’s Center for Substance Abuse Treatment (CSAT) and Division of Pharmacologic Therapies (DPT) of their intent to practice this form of medication-assisted treatment (MAT). The notification of intent (NOI), or buprenorphine waiver application, had to be submitted to SAMHSA before the initial dispensing or prescribing of OUD treatment medication (SAMHSA, 2022c). “Section 1262 of the Consolidated Appropriations Act of 2023 eliminates the federal requirement for practitioners to submit a Notice of Intent (NOI) or obtain a waiver before prescribing medications, such as buprenorphine, for treating opioid use disorder (OUD). As a result of this new provision, SAMHSA no longer accepts NOI or waiver applications (SAMHSA, 2023). As per the new regulation, all practitioners who possess a valid DEA registration that allows Schedule III prescribing authority may now prescribe buprenorphine for treating OUD in their practice, provided that it is permitted by their state laws. Practitioners can read more about this update, including new training requirements, at the SAMHSA website (SAMHSA, 2023).”
Medication for opioid use disorder (Formerly medication-assisted treatment [MAT]) The Substance Abuse and Mental Health Services Administration
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Book Code: AUS3024
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