high, while patients on high doses require a very slow taper). 23 ● The HHS guide allows for rapid tapers (e.g., over two-to-three weeks) when risks of continuing the opioid outweigh the risks of a rapid taper (e.g., in the case of a severe adverse event such as overdose) and further warns that ultrarapid detoxification under anesthesia is associated with substantial risks and should not be used. 73 A principle to remember is that slow tapers may require several months or years and are more appropriate than faster tapers for patients who have been receiving prolonged opioid therapy. 73 Rapid reduction of opioid doses should occur only if there is imminent danger to the patient from continuing doses (such as an overdose event at the current dose, medical complications, or dangerous behaviors such as injecting opioids), or in cases in which it is discovered the individual is obtaining pills to divert. 64,137 Tapering works best when it is collaborative between the HCP and the patient, when tapering is slow and careful, when support and close monitoring are offered, and when comorbidities such as depression, anxiety, and insomnia are concurrently addressed. 137 It is helpful to slow or to pause and restart tapering at times. There are serious risks to noncollaborative tapering in patients who have been prescribed opioids for a long period and have physical dependence, including acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, and patients seeking opioids from high-risk sources. 73 Include patients in discussions of taper planning and take time to gain patient buy-in to the plan whenever safety allows. It is of paramount importance to address opioid withdrawal symptoms (Table 8). 137 Early withdrawal symptoms (e.g., diarrhea and cramping, anxiety, restlessness, sweating, yawning, muscle aches) usually resolve after 5-10 days but can take longer. 73 Other post-acute withdrawal symptoms (e.g., dysphoria, Buprenorphine or slow taper in select patients In some patients on long-term opioid therapy, even on higher-than-recommended doses, with demonstrated benefit and no evident adverse effects, aberrant behavior, or major risks, taper may not be the best course of action. 137 Reports of harms after involuntary opioid discontinuation include overdoses, termination of care, emergent hospital or emergency department visits, and suicidal ideation or behavior. 137 Though other patient factors may also contribute to these behaviors, opioid stoppage in such patients, particularly when abrupt or nonconsensual, may put them at risk for poor outcomes. 137 Patients with worsened pain and function despite high daily opioid doses may exhibit a poor response to taper, whether or not OUD criteria are met, and may benefit from transitioning to buprenorphine. 73 Buccal and cutaneous patches of low-dose buprenorphine are FDA-approved for the treatment of pain, and buprenorphine/naloxone has been used off-label
insomnia, irritability) can take weeks or months to resolve. 73 Recommended oral medications to manage withdrawal symptoms (particularly for faster tapers) include alpha-2 agonists for autonomic symptoms such as sweating and tachycardia and symptomatic medications for muscle aches, insomnia, nausea, cramping, and diarrhea. 73 Tapering Follow-up and behavioral health support is very important during tapering. HCPs should acknowledge patient fears of pain, stigma, withdrawal, and abandonment while reassuring them that many patients have improved function after tapering, although the pain might be worse at first. 73,93 This is a time to collaborate with mental-health and other specialists and to watch closely for signs of OUD, anxiety, depression, and suicidal ideation. At least weekly follow-up has been used in successful tapers. 73 Table 8: Common Opioid Withdrawal Symptoms 137 Physical symptoms • Tremor • Diaphoresis
• Agitation • Insomnia • Myoclonus • Diffuse pain/hyperalgesia • Hyperthermia • Hypertension • Cramping/diarrhea • Pupillary dilation • Piloerection • Release of stress • hormones • Pain increase • Dysphoria • Anhedonia • Anxiety • Depression • Hopelessness/suicidal • ideation
Affective symptoms
as an analgesic for chronic pain. 137 buprenorphine has safety advantages over full mu agonists because respiratory depression tends to plateau as dose increases, and it is also less subject to dose escalation. Use of buprenorphine/naloxone to treat OUD no longer requires specific training, but a waiver from the Drug Enforcement Administration (DEA) is required to prescribe it. Practitioners are encouraged to receive training prior to use and there are new, short trainings that are freely available (see the following link: https:// elearning.asam.org/products/buprenorphine-mini- course-building-on-federal-prescribing-guidance#tab- product_tab_overview.) Transitioning from a full agonist opioid to the partial opioid agonist of buprenorphine requires careful attention to timing and may best be accomplished with consulting with an HCP experienced in its use. See the following link for support: https://pcssnow. org/.
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Book Code: MDCO1025
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