During PAINWeek 2018, in Las Vegas, Nevada, September 4-8, several presentations on opioids in pain management described strategies for tapering dosage to avoid withdrawal after extended use. Consideration was given to both the 2016 CDC guidelines that recommend tapering rather than abrupt discontinuation, and the FDA approval in May of lofexidine (Lucemyra, US Worldmeds) to reduce withdrawal symptoms.
Joseph Pergolizzi Jr, MD, Director of Research, NEMA Research, Inc, Naples, Florida, lead author of “Tapering Opioids: Clinical Strategies in Light of CDC Guidelines,” pointed out that long-term opioid therapy may need to be discontinued for a number of reasons, including resolution of the painful condition, intolerable side effects, tolerance necessitating dangerously high doses, development of opioid use disorder (OUD) or comorbid conditions that could be worsened by opioids, and polypharmacy causing adverse interactions with opioids. Pergolizzi’s caution: “Opioid prescribers should never initiate opioid therapy without an exit plan, which may involve tapering strategies."
“Opioid prescribers should never initiate opioid therapy without an exit plan..."
Pergolizzi recommended that tapering and discontinuing opioid therapy should follow a plan that has involved the patient, and often their family or others providing support. “Patients often require supportive care in this vulnerable time and may need help with pain control, tactics to manage withdrawal symptoms, and psychological or emotional comfort,” he indicated.
Myths about tapering
In reviewing the literature, Pergolizzi and colleagues found several "myths" about opioid tapering that continue to influence some practitioners, including that patients who have been on long-term opioids will not want them discontinued regardless of the resolution or improvement of a painful condition or the possibility of alternative therapies. Among the studies countering this notion was one that found 75% of 110 patients in a clinic with chronic non-cancer pain on long-term opioid treatment agreed to taper their dosage, if they could receive help from the clinic to do so.
"This suggests that patients may be hopeful to decrease or discontinue opioid therapy, providing there is a validated plan in place and they have extensive support as they moved forward," Pergolizzi observed.