Opioids
Sonya Collins
In the ongoing aftermath of the opioid crisis, it’s common for physicians to attempt to wean some patients off of opioids in favor of alternative means of pain management. But while the goal is increased safety for the patient, a recent study in JAMA revealed that opioid tapering does not come without risks.
The risk of mental health crises—including anxiety, depression, and suicide attempts—more than doubled during periods of tapering compared to periods of consistent opioid use, according to the study findings.
The risk of overdose nearly doubled during tapering periods as well. Overdose risk also increased with speed of dose reduction.
“Unfortunately, there are no surprises here. This adds to a number of articles with incredible data on these risks,” said Jeffrey Fudin, PharmD, an adjunct associate professor at Albany College of Pharmacy and Health Sciences in Albany, NY.
Pharmacists dispensing prescriptions for tapered opioid doses can work with patients and prescribers to help reduce these risks.
Opioid tapering and its risks
Evidence of the inherent dangers, including risk of overdose and mental health crises, associated with opioid tapering has prompted several health professional organizations—including the American Medical Association and Health Professionals for Patients in Pain—to petition CDC to make changes to its opioid use guidelines.
Among their proposed changes, the organizations requested that CDC acknowledge that decisions regarding when and how to taper or discontinue opioid prescriptions should be based on the individual patient, not determined by sweeping, universal guidelines.
“You need to justify the reason you’re going to taper,” Fudin said. “You shouldn’t just do it because there’s a policy that says a patient needs to be below X morphine milligrams equivalents. That’s absurd.”
In order to taper or discontinue opioids safely, as well as substitute opioid painkillers with other drugs, prescribers must take many patient factors into consideration, Fudin said.
These factors include pharmacogenetic profile, comorbidities, other medications, and the duration of opioid use.
Pharmacists can help reduce risk
When patients come into the pharmacy with a prescription for a tapered opioid dose, pharmacists can take several steps to ensure the taper is safe.
First, pharmacists should counsel patients on the risks associated with tapering and how to manage them.
Counseling should include discussion of adverse effects and symptoms of withdrawal and how to handle those, whether with a prescription medication such as clonidine or lofexidine or instructions to call their physician should these symptoms arise.
Patients might seek OTC medications—for example, for sleep—or alternative therapies, such as kratom, CBD, THC, or St. John’s wort to combat withdrawal and related symptoms.
Pharmacists need to be well-versed in the risks of kratom and other remedies patients could seek, including the interactions these could have with opioids or other medications the patient is taking.
“Pharmacists should tell patients not to take any new medications, over-the-counter [medications], or natural remedies without consulting the doctor or the pharmacist first,” Fudin said.
Pharmacists should discuss the risk for mental health crises, how to recognize the signs, and what the patient should do in the event of these symptoms.
Finally, in addition to stressing the risk of opioid overdose, pharmacists should offer naloxone to patients on a robust opioid taper in states where they are authorized to do so.
Fudin suggests that patients should not be permitted to waive counseling when the prescription reflects significant reduction in opioid dose.
“Pharmacies can’t make a policy that’s more lenient [around counseling], but any pharmacy can make a policy that’s less lenient.”
When an opioid taper seems too steep, Fudin advises pharmacists to call the prescriber to ask about the reason and discuss the risks.
“This can be a touchy subject for physicians, so obviously approach it in a professional manner, but pharmacists need to have these conversations,” he said.