How do you avoid punitive sudden discontinuation of opiates?

How to Avoid Punitive Sudden Discontinuation of Opiates

Unless there is a life-threatening issue such as warning signs of imminent overdose, the benefits of rapidly tapering or abruptly discontinuing opioids are unlikely to outweigh the substantial risks of these practices, which include mental health crisis, overdose events, withdrawal symptoms, and death. 1

Core Principles to Prevent Punitive Discontinuation

Never Abruptly Stop Opioids

• Abrupt discontinuation has been directly associated with overdose death, suicide, mental health crisis, emergency department utilization, and patients self-medicating with illicit substances 1
• Discontinuation of long-term, high-dosage opioid therapy was associated with increased risk for suicide and paradoxically increased overdose risk in some studies 1
• Physical dependence develops after several days to weeks of continued use, and abrupt cessation precipitates withdrawal characterized by restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, mydriasis, anxiety, insomnia, abdominal pain, vomiting, diarrhea, and tachycardia 1, 2

Engage in Shared Decision-Making

• When clinicians and patients cannot agree on whether tapering is necessary, acknowledge this discordance, express empathy, and seek to implement treatment changes in a patient-centered manner while avoiding patient abandonment 1
• Voluntary, patient-centered opioid reduction after discussion with patients who agreed to taper was associated with improved pain, function, and quality of life 1
• Involuntary or nonconsensual tapering has documented harms including overdoses, termination of care, and suicidal ideation, whereas consensual tapering mostly yields good results with minimal documented harms 1
• Simply giving the patient the name of another healthcare professional is inadequate and ineffective—clinicians must offer care or obtain agreement from others to provide this care 1

Safe Tapering Protocol When Discontinuation is Necessary

Taper Speed and Method

• For patients on long-term opioids (≥1 year), tapers of 10% per month or slower are likely to be better tolerated than more rapid tapers 1
• Each new dose should be 90% of the previous dose, not a straight-line reduction from the starting dose 3
• Longer duration of previous opioid therapy requires a longer taper—tapers can be completed over several months to years depending on opioid dosage 1
• Slower tapers of 5-10% reductions may be necessary for patients on higher doses or who have been on opioids for years 3

Monitoring and Support During Tapering

• Maximize nonopioid treatments for pain and address behavioral distress before and during the taper 1
• Clinically significant opioid withdrawal symptoms signal the need to further slow the taper rate 1
• Tapers may need to be paused and restarted when the patient is ready, and may need to be slowed as patients reach low dosages 1, 3
• Remain alert to and screen for anxiety, depression, and opioid use disorder that might be revealed by an opioid taper 1
• Provide frequent support through telephone contact, telehealth visits, or face-to-face visits 3

Managing Withdrawal Symptoms

• Withdrawal distress should be preempted and managed with adjuvant medications for specific symptoms such as anxiety and insomnia 1
• Pain itself may be a withdrawal symptom and not simply an exacerbation of original chronic pain, as descending pain facilitatory tracts show increased firing during early abstinence 1
• Fear of withdrawal is a primary reason patients continue long-term opioid therapy and must be taken seriously and addressed 1

Special Considerations

When Tapering Should Not Occur

• Do not insist on opioid tapering or discontinuation when opioid use might be warranted (i.e., when benefits of opioids outweigh risks) 1
• Tapering is essential only if patients are in serious danger because of medical complications, overdose, or hazardous behaviors 1
• Access appropriate expertise if considering tapering opioids during pregnancy because of possible risk to the pregnant patient and fetus if the patient goes into withdrawal 1

Alternative Approaches

• Consider switching to buprenorphine, especially if the patient has aberrant behaviors or opioid use disorder 1, 4
• Buprenorphine initiation requires discontinuing all opioids the night before, waiting for mild withdrawal, then initiating 2-4 mg repeated at 2-hour intervals until resolution of withdrawal symptoms 1
• For patients with opioid use disorder, medications for opioid use disorder (buprenorphine or methadone) are preferred over withdrawal management 1

Overdose Risk After Discontinuation

• Advise patients of increased risk for overdose on abrupt return to a previously prescribed higher dose because of loss of opioid tolerance 1
• Provide opioid overdose education and offer naloxone 1
• Death rates for overdose or suicide increased immediately after stopping opioids, with incidence decreasing over approximately 3-12 months 1

Common Pitfalls to Avoid

• Never use "cold referrals" to other clinicians who have not agreed to accept the patient during taper 3
• Do not use straight-line tapers that subject patients to increasingly large absolute dose reductions as they approach zero 3
• Do not mandate zero as the target dose for all patients—some may require long-term low-dose maintenance 3
• Do not taper faster than 10% per month for long-term users, as this increases risk of withdrawal and relapse 3
• Before reversing a taper, carefully assess and discuss with the patient the benefits and risks of increasing opioid dosage 1, 3