News from PAINWeek 2018: "Tapering [opioids] is not detoxification," was one among many cautions and recommendations offered during several presentations in Las Vegas, Sept 4-8.
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."
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.
Tapering is not detoxification
Pergolizzi and colleagues shared several best practices from their review of the literature to ensure that tapering is not aimed solely at detoxification, but is a stepwise and incremental process that weans the patient off opioids while minimizing discomfort.
âº The daily dose of opioids needed to prevent acute withdrawal symptoms is approximately 25% of the previous day's dose.
âº If a patient is receiving opioids through different routes of administration, such as transdermal and oral, it may be advisable to convert to a single, extended-release oral product before tapering.
âº If different opioid products are being used, conversion to a single product should be at roughly the equivalent dose over 24 hours, often expressed in morphine milligram equivalents (MME).
âº The highest daily morphine equivalent dose (MED) recommended by the CDC is 90mg. Although many patients take higher doses due to tolerance, it is noted that both high dose and extended duration of use are risk factors for OUD.
âº Short-acting opioids may be helpful at both the initiation and end of tapering the extended-release product, to avoid withdrawal.
In a separate presentation on managing withdrawal symptoms in opioid patients, Pergolizzi and colleagues described both the physical symptoms as well as physiologic processes involved. While there is patient variability, they note, the symptoms will typically begin within 24 or 48 hours of discontinuing the short-acting, or long-acting opioid, respectively. Late withdrawal symptoms may differ from those manifesting earlier, they point out, and will likely include intense drug craving.
A variety of medications have been used to provide symptomatic relief, Pergolizzi and colleagues point out, with lofexidine now available as the first FDA approved nonopioid treatment for withdrawal symptoms. Pergolizzi and colleagues presented data on lofexidine in a PAINWeek presentation titled “Lofexidine: Not Just Your Father's Alpha-2 Agonist.”