On The Cover
Loren Bonner
Four members of the interdisciplinary chronic pain management care team at Kaiser Permanente, Mid-Atlantic States in Northern Virginia (from left to right): Victoria Bacsardi, MSW, LCSW, MAC, pain psychology therapist; Judith Jones, PharmD, MPH, BCPS, clinical pharmacy pain management specialist; Emma Boateng, RN, BSN, navigator/coordinator chronic pain management; Sharat Narayanan, MD, chronic pain management physician.
What happens when a network of pain clinics in a town closes and 20,000 chronic pain patients are scrambling for care? In upstate South Carolina this year, when most of the pain clinics in the area shuttered their doors, providers came together to help.
Knowing about opioid tapering was one of the priorities for the physicians, emergency department staff, and pharmacists who banded together to help their community. Through it all, Kelly Hunt, RPh, owner of FirstChoice Pharmacy in Duncan, SC, said it took about 30 days for most patients to find another physician, which left some patients short on their medications.
“As pharmacists, we extended extra measures of grace and compassion as we listened to them and looked for solutions. Some patients simply needed to vent their frustrations and talk out their issue. Others were suffering and beginning to panic,” said Hunt.
Several times, pharmacists at his store called other practices to see if they were accepting new patients, he said. Most patients have a hard time finding a new provider who will care for them. In fact, research published in July 2019 by Lagisetty and colleagues in JAMA Network Open found that more than 40% of primary care physicians will not treat a prospective new patient who uses opioids.
“Other times, we instructed patients on how to make the medications they had remaining last a few days longer and help ease the symptoms of withdrawal,” Hunt said.
While the situation in upstate South Carolina may be unique, it highlights the need for more awareness and education in this area. Misapplied CDC guidelines have encouraged hard limits and abrupt tapering of opioid drug doses as physicians have been pressured to reduce opioid prescriptions. All of this, combined with many providers who are reluctant to take on chronic pain patients, has created a negative ripple effect for patients.
But experts in the field are coming together to try to solve some of the unknowns, as well as other challenges of opioid tapering for patients and clinicians within the bigger picture of proper pain management.
“What’s changing is the increasing awareness that we are not doing deprescribing well,” said Kate Nicholson, JD, cochair of the Chronic Pain/Opioids Task Force for the National Centers on Independent Living.
Although evidence-based best practices do not yet exist for opioid tapering, the base is building through various research efforts and more. Not only are efforts under way at the public health level, but the National Academy of Medicine (NAM), as well as federal agencies, are coming out in front on the issue. In July 2019, NAM held a public webinar on opioid tapering, and the academy is expected to release a discussion paper on the topic this year.
The U.S. Department of Health and Human Services (HHS) issued a guide for clinicians in October 2019 on proper opioid tapering, noting a need for personalized care and including a strong recommendation not to taper opioids rapidly or discontinue them suddenly.
Last year, FDA and CDC released statements warning of the dangers of rapidly discontinuing or decreasing the dose of opioids for patients.
Shared decision making and a team of providers
Opioid tapering represents an opportunity to engage patients in a supportive shared decision-making strategy, according to Anna Legreid Dopp, PharmD, director of clinical guidelines and quality improvement at the American Society of Health-System Pharmacists (ASHP).
“Once the patient or provider has determined that an opioid taper is the best course of action, a tapering plan can be made that assures the patient of the expectations and process. Typical tapering plans include elements such as start and stop points, proposed speed, potential withdrawal symptoms, and a plan for addressing breakthrough pain,” she said.
In an ideal situation, the process to taper a patient off opioids involves a team of health care providers.
“Opioid tapering requires collaboration between patients, providers, and pharmacists along with shared decision making,” said Lisa Hines, PharmD, vice president of performance measurement and operations at the Pharmacy Quality Alliance. Hines is also a member of NAM’s Action Collaborative on Countering the U.S. Opioid Epidemic.
“Pharmacists can also be the voice to start the conversation about the benefits of tapering,” she said.
Judith Jones, PharmD, MPH, BCPS, has a mindset for success when she develops an opioid tapering plan for a patient.
Taking a patient-centered approach, the first thing she does is make sure the plan is individualized.
“There are standards of care based on CDC guidance, which include a lower, safer morphine milligram equivalent goal of less than 90, but it is important to develop an individualized care plan for each patient,” said Jones, who is a clinical pharmacy pain management specialist at Kaiser Permanente in Springfield, VA.
Jones first reviews the patient’s chart and looks for other comorbidities, such as mental health conditions, cardiovascular disease, and renal or hepatic dysfunction.
“For patients with comorbid anxiety [or] depression, it’s very hard to start a taper if depression and/or anxiety are not adequately controlled—we set up a patient for opioid taper failure. It may be necessary to address the mental health conditions prior to starting an opioid taper,” said Jones. One of her main roles is designing opioid dose tapers for physicians at Kaiser Permanente Mid-Atlantic States.
Jones said tapers can often be anxiety-provoking for patients.
“It might reveal undiagnosed anxiety,” she said. “I encourage physicians to conduct an in-office visit, if possible, to discuss the proposed opioid dose taper, to set expectations, and to get the patient’s input and allay any fears.”
She said the hardest part is often introducing the idea of a taper to patients, especially those who have been taking a prescribed opioid for several years.
“As we implement an opioid dose taper, the provider or pharmacist should assess a patient’s progress periodically, particularly assessment of withdrawal symptoms,” Jones said.
If the patient is experiencing withdrawal symptoms—which can be very unpleasant and distressing but not life-threatening—Jones advises the physician to consider slowing down the taper by decreasing the dose or increasing the interval between the taper. They can also hold the taper where it is until the patient’s symptoms stabilize. It may be necessary to provide medications targeted at a particular withdrawal symptom.
Some patients may improve after the dose of the opioid is lowered. Jones added that while tapering, clinicians must still address the patient’s pain and functionality.
“This is a multidisciplinary chronic pain care model where the patient is seen by a pain medicine physician, a clinical pharmacy pain specialist, and a pain psychologist,” said Jones. “The three of us meet to discuss our recommendations for improved pain control and function for each patient.”
Trying to fix what went wrong
HHS’s new guidelines for clinicians, called the Guide for Clinicians on the Appropriate Dosage Reduction on Discontinuation of Long-Term Opioid Analgesics, provide recommendations for clinicians who are considering or initiating a change in a patient’s opioid dosage. Their message is clear: If a patient and provider decide to begin tapering, it must be done slowly and carefully.
In a statement issued with the release of the guide, HHS said it does not recommend that opioids be tapered rapidly or discontinued suddenly because of “the significant risks of opioid withdrawal, unless there is a life-threatening issue confronting the individual patient.”
The agency continued that once a patient is on opioids for a prolonged duration, “any abrupt change in the patient’s regimen may put the patient at risk of harm and should include a thorough, deliberative case review and discussion with the patient.”
“[The report is] timely, and I hope pharmacy organizations are working to disseminate it more broadly,” said Hines.
Nicholson agrees that it’s useful right now, but she expressed concerns that pressures in the current environment still incentivize forced or abrupt tapers for patients, and even patient abandonment.
The HHS guidelines are a reaction of sorts to this environment that’s been created for some chronic pain patients. CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain seemed to encourage hard limits and abrupt tapering of opioid drug doses as pressures mounted to reduce opioid prescribing. Insurance companies, states, provinces, and other government groups used the guideline as an opportunity to create hard-and-fast rules. Along the way, prescribers became fearful, and some went so far as to “fire” chronic pain patients from their practices.
Last year, authors of the 2016 CDC guideline had to clarify what they intended all along—that the guideline was a series of suggestions to improve prescribing practices, not a regulation. In a commentary published in the New England Journal of Medicine in April 2019, they cautioned against policies and practices that misapply the recommendations and wrote that many of them that have been adopted are inconsistent with the original recommendations.
In addition, an HHS special task force report released last year included 18 specific recommendations to improve the CDC guideline, grouped into updating the scientific evidence since the release of the guideline, and emphasizing or expanding the content of the guideline.
The report, from the Pain Management Best Practices Inter-Agency Task Force (PMTF), created through the Comprehensive Addiction and Recovery Act of 2016, considered the gaps and inconsistencies for acute and chronic pain management while outlining appropriate pain management. The report emphasized a multidisciplinary approach to pain management using one or more treatment modalities. However, it also recognized the gaps: How is physical therapy possible for a patient, for example, if a generic opioid prescription costs less? The report is intended to be a resource and guide for health care practitioners and patients alike, as well as policymakers.
Jones said that at Kaiser Permanente, which is an integrated health system, their approach to chronic pain in general is multimodal. She tries to incorporate or optimize nonopioid treatment options, such as acetaminophen or NSAIDs, as first-line treatments.
“I also make recommendations to incorporate nonpharmacological modalities, particularly acupuncture, physical therapy, and cognitive behavioral therapy as appropriate,” said Jones.
Nicholson noted that what works best for opioid tapering—a multimodality approach—is what works best for pain management in the first place. But once again, policies have to be aligned.
Research to note
As with pain management, flexibility should be in place with opioid tapering. A one-size-fits-all approach does not work on either end.
Beth Darnall, PhD, associate professor in the division of pain medicine at Stanford University, said systems also need to be in place to help patients who may be having negative experiences with opioid reduction. “That could be increased pain, withdrawal symptoms, or something else. There is an ethical imperative to monitor patients closely and address their problems. For some patients, opioid reduction may not be beneficial based on their response,” said Darnall, who is also the principal investigator for the Stanford PCORI Project on Opioid and Pain Reduction, also known as the EMPOWER study.
While many studies focus on opioid dose and fail to characterize or document the patient experience, EMPOWER is looking at the degree of choice patients feel they have in the decision to taper, as well as their readiness to taper. The research considers many aspects of the patient experience, including a check-in with patients weekly to understand whether they are having any discomfort with the opioid taper and adjusting the care plan according to their needs.
“We believe that patient choice and readiness are critical predictive factors that are underappreciated. We need to do better at characterizing the patient experience and developing methods that support patients toward choice and readiness rather than forcing patients,” said Darnall.
Her research team is also testing the comparative effectiveness of two behavioral medication treatments within the context of opioid reduction.
“This is important because it gets to the core of what’s missing: We are conducting patient-centered tapering while providing the multimodal pain treatment that we know addresses the multidimensional nature of chronic pain,” she said.
ASHP’s Legreid Dopp said that although recent studies and guidance documents have addressed opioid tapering, more research is needed on the topic. She cited unanswered questions about tapering patients on multiple medications; preferred speed of the taper; use of adjunctive therapies or FDA-approved medications for opioid use disorder; and managing patients with undiagnosed or unaddressed behavioral health issues.
Opioid tapering resources