October 14, 2019

HHS on Thursday released a guide outlining the steps clinicians should take to taper patients off of opioid prescriptions without causing patients harm.

Struggling to confront the opioid epidemic? Start here.

Background

As concerns about the opioid epidemic grew, CDC in 2016 released guidelines to reduce unnecessary opioid prescribing. In 2017, the year after the guidelines were released, opioid prescribing fell 10%, according to a 2018 report by IQVIA's Institute for Human Data Science.

However, with the 2016 guidelines came concerns that providers may be unsafely lowering opioid prescription dosages for chronic pain patients and failing to offer appropriate support to help patients transition off the drugs, STAT News reports. Some patients whose opioid prescriptions were aggressively reduced have turned to illicit sources or considered suicide.

Further, experts said the guidelines' recommendation that providers "work with patients to taper opioid to lower dosages or to taper and discontinue opioids" led insurers to reject claims for opioid prescriptions.

In response to these concerns, CDC officials in an April letter clarified that the opioid prescribing guidelines should not be used to deny opioid drugs to patients experiencing chronic pain caused by cancer or sickle-cell disease.

Guideline details

HHS in the latest guide aims to further address these concerns, STAT News reports. Brett Giroir, HHS' assistant secretary for health, on Wednesday said the latest guidelines reflect "a very large body of data across the scientific and medical literature that would say that abrupt discontinuation or abrupt reduction in dosage can be harmful to patients." He added that the evidence also shows "a majority of patients can have a reduction in opioids and improve pain control at the same time." He also noted the guidelines are "not a mandate or a rule that works for every single patient."

Overall, HHS recommends providers and patients come to a decision to reduce opioid dosages together. The guide provides a number examples of when providers should consider tapering patients off the drugs. For instance, HHS recommends providers reduce a patient's opioid dosage if the drug is not controlling the patient's pain, if a patient is experiencing side effects, or if a patient begins to take certain new medications, including benzodiazepines.

According to the guide, patients who are successfully tapered to lower dosages of opioids can see improvements in their sleep, mood, and overall daily function without their pain returning.

However, HHS in the guide also acknowledges the risks of rapidly tapering patients off opioids. For example, the guide notes patients who are quickly tapered off the drugs can experience withdrawal symptoms.

Still, the guidance states there are cases in which a patient might need to be abruptly taken off of opioids—including when providers have concerns about potential overdoses or other life-threatening side effects.

The guide explains providers "should never abandon" patients who tapered off opioids. According to the guide, opioid doses are generally decreased by 5% to 20% a week, but tapering patients off opioids more slowly often helps reduce the likelihood of withdrawal symptoms. Deborah Dowell, the chief medical officer of CDC's division of unintentional injury prevention, said there are no specific targets providers should strive to reach when they reduce a patient's opioid dosages. Instead, providers and patients should seek to find a dosage level where the benefits outweigh the risks, she said.

For patients who have difficulty tapering off opioids, the guide recommends providers them buprenorphine, a medication-assisted treatment for opioid-related substance use disorders.

Reaction

Salimah Meghani, an associate professor of nursing and a pain researcher at the University of Pennsylvania who has criticized CDC's previous prescribing guidelines, said CDC's guidelines had "led to wide-scale inappropriate opioid tapering or simply dumping of complex pain patients," but the latest guide "provides important and much-needed clarification." However, she said more needs to be done, including addressing state-level mandates reducing opioid dosages to below 90 morphine milligram equivalents (Joseph, STAT News, 10/10; Stone/Aubrey, "Shots," NPR, 10/10; Achenbach, Washington Post, 10/10; Goodnough, New York Times, 10/10).

Struggling to confront the opioid epidemic? Start here.

The opioid epidemic is a complex, multi-dimensional public health problem. Use this list of helpful resources on how hospitals and health systems can play a role to treat opioid addiction and prevent further increase in opioid abuse.

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