● Patient experiences side effects that diminish quality of life or impair function ● Patient experiences overdose or other serious event (e.g., hospitalization, injury) or has warning signs (e.g., confusion, sedation, slurred speech) for an impending event ● Risk for adverse outcomes is increased through co-administration of medications (e.g., benzodiazepines) or medical conditions (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) ● Long-term opioid administration has been prolonged (e.g., years) and current benefit-harm balance is unclear HCPs should ensure patient understanding of tapering plan while maintaining that the plan remains patient centered. In considering whether opioids or other CS continue to meet treatment goals, evaluate risks versus benefits and avoid insisting on tapering or discontinuation when opioid use may be warranted (e.g., treatment of cancer pain, pain at the end of life, or other circumstances in which benefits outweigh risks of opioid therapy) . HCPs should avoid dismissing patients from care. Instead, refer patients for medication treatment for OUD (MOUD) as described below and ensure that patients continue to receive coordinated care. 79 Patients who are discontinued or tapered non- collaboratively are at risk for acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, opioid overdose, and seeking opioids from high-risk sources. 5,79,80 Taper without the patient’s consent is a challenging situation and the risks versus benefits of treatment should be clearly defined. If the prescriber decides that the risks of the treatment outweigh the benefits, the prescriber may need to recommend taper. One should continue to treat pain and withdrawal with pharmacologic and nonpharmacologic options. If the patient has serious mental illness, a high suicide risk, or suicidal ideation, offer or arrange for consultation with a behavioral health provider before initiating a taper. 79 Treating common comorbid mental disorders (e.g., depression, anxiety, and PTSD) can improve the likelihood of opioid tapering success and reduce dropouts. 79 Access appropriate expertise if considering opioid tapering or managing OUD during pregnancy. 79 Opioid withdrawal risks include spontaneous abortion and premature labor. For pregnant women with OUD, MOUD is preferred over detoxification. HCPs should advise patients that there is an increased risk for overdose on abrupt return to a previously
prescribed higher dose. 79 One should strongly caution them that it takes as little as a week to lose tolerance. Patients should be provided with opioid overdose education and possibly offered naloxone. Taper should be slow enough to minimize opioid withdrawal, and longer duration of therapy entails slower taper (common tapers involve dose reductions of 5% to 20% every 4 weeks). Signs of withdrawal with opioids occur when stopping or decreasing doses or administering an opioid antagonist. Acute opioid withdrawal symptoms include drug craving, anxiety, restlessness, insomnia, abdominal pain or cramps, nausea, vomiting, diarrhea, anorexia, sweating, dilated pupils, tremor, tachycardia, piloerection, hypertension, dizziness, hot flashes, shivering, muscle or joint aches, runny nose, sneezing, tearing, yawning, and dysphoria. 79 Pain often worsens with withdrawal and, although the pain may be prolonged, it does tend to diminish over time for many patients. 79 If patients on high opioid dosages are unable totaper despite worsening pain and/or function, whether OUDcriteria are met, HCPs may consider transitioning to buprenorphine. Buprenorphine is a partial opioid agonist that can treat pain as well as OUD, result in less opioid- induced hyperalgesia (i.e., heightened pain response), and easier withdrawal than full mu- agonist opioids, and less respiratory depression than other LA opioids. 79 Treatments for withdrawal symptoms include alpha-2 agonists clonidine and lofexidine. 79 Other medications may be NSAIDs, ACET, or topical menthol/methyl salicylate for muscle aches; trazodone for sleep disturbance; prochlorperazine, promethazine, or ondansetron for nausea; dicyclomine for abdominal cramping; and loperamide or bismuth subsalicylate for diarrhea. 79 Some patients are taking opioids and benzodiazepines concurrently, and one or both medications are to be tapered. Although tapering may be accomplished more rapidly in a controlled setting like a detox unit, benzodiazepines must be tapered gradually in the outpatient setting due to risks of withdrawal that include anxiety, hallucinations, seizures, delirium tremens, and, in rare cases, death. 79 Long-acting benzodiazepines should be slowly discontinued over several months. 61 If needed, gabapentinoids, carbamazepine, or valproic acid may help facilitate self-managed reduction or normalize sleep, reflexes, and anxiety. 60,81-84
TREATING OPIOID-USE DISORDER
At least 2.35 million people in the United States have OUD involving prescription opioids, illicit opioids such as fentanyl and heroin, or a combination of these. 16 Yet over 70 percent of people who needed treatment for OUD in 2017 did not receive it. 16 The recommended evidence-based treatment for OUD is MOUD, which is treatment with medication combined with behavioral counseling and such services as case management and
peer support. FDA-approved medications for OUD are methadone, buprenorphine, and extended-release naltrexone. MOUD relieve the withdrawal symptoms and psychological cravings and are safe to use for months, years, or even a lifetime. Patients who are suffering with OUD (or another SUD involving a CS) need encouragement to seek treatment and reassurance that they are not trading
Book Code: TN24CME
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