Should patients taking opioids (narcotics) for chronic pain management undergo medication holidays?

From the Guidelines

Patients taking narcotics for chronic pain should not be routinely recommended to take drug holidays, as the decision to taper or discontinue opioids should be made on an individualized basis, considering the potential benefits and risks, and under close medical supervision. The CDC clinical practice guideline for prescribing opioids for pain [ 1 ] emphasizes the importance of weighing the benefits and risks of opioid therapy, including the potential for opioid use disorder, overdose, and other adverse events.

When considering tapering or discontinuing opioids, clinicians should involve patients in decisions regarding continuation or discontinuation of opioid medications, and practices including behavioral support, integration of nonpharmacologic pain management, and slower tapers might improve outcomes [ 1 ]. A taper support intervention, including psychiatric consultation, opioid dosage tapering, and weekly meetings with a physician assistant to explore motivation for tapering and learn pain self-management skills, was associated with better functional outcomes compared with usual care [ 1 ].

Some key points to consider when deciding whether to recommend a drug holiday include:

• The patient's individual circumstances, including the severity of their pain condition and their history of substance use disorders
• The potential benefits of tapering or discontinuing opioids, including reducing tolerance and minimizing side effects
• The potential risks of tapering or discontinuing opioids, including withdrawal symptoms, exacerbation of pain, and increased risk of overdose or mental health crisis
• The importance of involving patients in decisions regarding continuation or discontinuation of opioid medications, and providing behavioral support and nonpharmacologic pain management strategies during the tapering process.

Overall, the decision to recommend a drug holiday for patients taking narcotics for chronic pain should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances, and under close medical supervision [ 1 ].

From the Research

Medication Holidays for Patients Taking Narcotics

• Medication holidays refer to the deliberate interruption of pharmacotherapy for a defined period and for a specific clinical purpose, as stated in the study 2.
• The purpose of medication holidays can be for the assessment of efficacy and tolerability of a drug therapy, or for a therapeutic benefit, such as alleviating adverse effects 2.
• Medication holidays have been hypothesized to "resensitize" neurons to the acute pharmacological effects of a drug, potentially reversing physiological adaptive effects from chronic pharmacological stimulation 2.

Potential Problems with Medication Holidays

• Potential problems associated with medication holidays include the risk of destabilizing patients, difficulty in distinguishing rebound and discontinuation effects, and increasing the risk of poor medication adherence 2.
• There is no direct evidence in the provided studies to suggest that patients taking narcotics for chronic pain should take drug holidays, but the concept of medication holidays can be applied to various pharmacotherapies, including opioids.

Opioid Therapy for Chronic Pain

• Opioids can be effective for chronic pain management, but their use is associated with a significant number of side effects and complications, including constipation, nausea, sedation, and physical dependence 3.
• Combination therapies, such as oxycodone/naloxone, may provide effective analgesia with limited disturbing effects on bowel function, which is a common side effect of opioid therapy 4.
• Patient screening, education, and preemptive treatment of potential side effects may aid in maximizing the effectiveness of opioid therapy while reducing the severity of side effects and adverse events 3.