Other life circumstances that may accompany OUD but are not always seen include: 151 • Marital problems, including divorce • Unemployment and irregular employment • Financial insecurity • History of drug-related crimes SUDs involving alcohol or any other drug may threaten the success of opioid therapy and introduce safety risks. SUD should be suspected when the recurrent use of alcohol or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home. The coexistence of both a mental health and an SUD is referred to as co- occurring disorders. The National Institute for Mental Health’s Mental Health Information website has information about specific mental conditions and disorders as well as their symptoms: https:// www.nimh.nih.gov/health/topics/. The presence of a psychiatric or substance-use condition does not mean the patient is not experiencing real pain. The many contributing factors from the biological, psychological, and social domains as well as chronic pain’s adverse impact on relationships, work, sleep, function, overall health, and quality of life explain why a comprehensive approach to pain management is optimal. 14 These complexities also explain why patients often respond better to a combination of therapeutic modalities rather than a unimodal medication regimen. Tapering Before initiating opioid therapy, HCPs should have an exit strategy in place to humanely taper opioids whether the goal is dose reduction or to discontinue opioid therapy. Indications for discontinuing opioid therapy may include: 72 • Failure to achieve sufficient analgesia • Intolerable side effects • Resolution of pain • Development of OUD or serious misuse • Higher doses without evidence of benefit • Presence or warning signs of an impending serious event (e.g., confusion, sedation, slurred speech) • Concurrent medications (e.g., benzodiazepines) that increase risk for a serious outcome • Concurrent medical condition(s) (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) that increase risk for a serious outcome • A pattern of ongoing failure to adhere to the treatment plan to which the patient agreed Signs of serious nonadherence that may indicate opioids are unsafe for the patient include: 77 • Repeatedly increasing dose without HCP knowledge • Sharing medications • Unapproved opioid use • Use of illicit drugs
• Obtaining opioids from unauthorized sources • Prescription forgery • Multiple episodes of losing prescriptions • Polysubstance use The CDC suggests evaluating new patients currently on >90 mg MMD daily opioid dose or whenever risks outweigh benefits for tapering protocol, 61 while the VA/DoD practice guideline recommends a comprehensive reassessment that recognizes the risks of the high dose. 20 However, one must beware of abrupt opioid discontinuation and know that treatment is individualized. 1,15-17,20 The CDC guideline is meant to advise HCPs to avoid increasing doses above 90 mg MME daily but is not meant to circumscribe individualizing treatment or to justify abrupt reduction from high doses. 72 Nor is the guideline meant to justify reducing or discontinuing opioids that may be medically indicated and when benefits outweigh risks. 72 Patients who are candidates for taper should be treated with alternatives to opioid therapy for pain. HCPs should avoid dismissing patients from care and should ensure whenever possible that patients continue to receive coordinated care. 72 Referral should include, as indicated, treatment of OUD or management of psychiatric illnesses. 119 In an outpatient setting, taper should be done so as to avoid opioid withdrawal in physically-dependent patients. Taper may be accomplished in a detox setting if the patient is unable to reduce opioid dose. An expert consensus guideline offered the following recommendations regarding tapering opioids: 20 • Evaluate comorbidities, the patient’s psychological condition, and other relevant factors before beginning the taper • Educate the patient and family about the taper protocol • Manage withdrawal symptoms (e.g., nausea, diarrhea, muscle pain, myoclonus) using non- opioid analgesics and adjuvant agents • For complicated withdrawal symptoms, refer the patient to a pain specialist or chemical dependency center • Refer for counseling or other support during the taper if there are significant behavioral issues Diversion of opioids or other controlled substances is a contraindication for continuing opioid therapy. 20 With confirmed diversion, the best practice is to monitor for withdrawal symptoms, offering necessary support and treatment of SUD, if present. 20 There is no one established taper rate that will work best for every patient. 1,15-17,20 Certain characteristics will influence the recommended speed of tapering. These include opioid dose, duration of therapy, type of opioid formulation, and co-occurring psychiatric, medical, and substance- use conditions. 20 Various rates have been studied or recommended by experts:
• The CDC recommended 10% per week reduction as a starting point. 152 • A more recent HHS guide suggested individualized tapering plans that range from slower tapers of 10% per month (or slower) to faster tapers of 10% per week until 30% of the original dose is reached, followed by 10% weekly reductions of the remaining dose. 72 • The VA/DoD practice guideline suggests 5% to 20% reduction every four weeks, individualizing according to patient need (e.g., some patients may need or tolerate a faster taper when risks are too high, while patients on high doses require a very slow taper). 20 • 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 72 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. 72 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. 61,144 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. 144 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. 72 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 9). 144 Early withdrawal symptoms (e.g., diarrhea and cramping, anxiety, restlessness, sweating, yawning, muscle aches) usually resolve after 5-10 days but can take longer. 72 Other post-acute withdrawal symptoms (e.g., dysphoria, insomnia, irritability) can take weeks or months to resolve. 72 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. 72
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