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Department issues guideline on tapering and discontinuation

Clinicians seeking to wean patients off opioid painkillers should do so slowly and only with shared decision-making involving the patient, according to a new guideline released Thursday by the Department of Health and Human Services (HHS).

The lone exception is when patients face a life-threatening crisis if opioids are continued, the document stated.

HHS also lists situations in which clinicians should consider tapering dosages or discontinuing opioids altogether, starting with “Pain improves” and ending with “The patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear.”

In between are common-sense scenarios including patient request, overdose, evidence of misuse, and use of other medications that shouldn’t be combined with opioids.

Sudden Tapering is Risky

But the guideline’s main thrust is to discourage clinicians from simply stopping prescriptions abruptly.

“Risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients include acute withdrawal symptoms, exacerbation of pain, serious psychological distress, and thoughts of suicide,” the document emphasizes in a colored box. It also notes, perhaps unnecessarily, that “patients may seek other sources of opioids, potentially including illicit opioids, as a way to treat their pain or withdrawal symptoms” if suddenly deprived without their agreement.

Among the steps clinicians should take before changing doses were making a commitment “to working with your patient to improve function and decrease pain.” This could include alternative medications as well as nonpharmacological treatments, the document indicates, adding, “Integrating behavioral and nonopioid pain therapies before and during a taper can help manage pain and strengthen the therapeutic relationship.”

“Obtain Patient Buy-In”

The guideline also advocates a thorough discussion with patients that includes soliciting their perceptions of the risks and benefits of continuing on opioids.

Notably, it also states that “tapering does not need to occur immediately. Take time to obtain patient buy-in.”

Included in the guideline is a multi-step flow chart to walk clinicians through the decision-making process, from the initial assessment of benefits and risks of patients’ current regimens to a recommended quarterly re-evaluation of patients’ progress. And, also in a colored box, is the definition of opioid use disorder as given in the DSM-5 diagnostic manual.

“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, MD, assistant HHS secretary for health, in a statement announcing the guideline. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”

Originally published in MedPage Today

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