Federal health officials on Thursday released a guide for clinicians who are considering tapering patients’ opioid prescriptions, highlighting the benefits of safe reductions in dosages while warning against abrupt drops for people who have been on the drugs for long periods.
The recommendations come amid concerns that some chronic pain patients’ dosages have been unsafely pulled back and that providers have sometimes abandoned patients. Some experts and advocates have warned that overly aggressive reductions or forced cutbacks have led some patients who are dependent on the drugs to seek out illicit sources of opioids or consider suicide.
The anxiety around prescribing built in response to the opioid crisis, which drove more than 47,000 fatal overdoses in 2017 alone. The crisis was caused in part by some clinicians overprescribing the drugs, leading to cases of addiction in patients and a source of pills that were diverted. Prescribing levels have dropped since 2012, and some advocates have warned that the fear around opioids has left some patients unable to get them.
The new guide marks the government’s attempt to strike a balance between reducing the amount of opioids prescribed and ensuring patients aren’t left behind. It also reflects concerns that prescribing guidelines released by the government in 2016 were misapplied and contributed to inappropriate tapers.
On a call with reporters Wednesday, Dr. Brett Giroir, an assistant secretary at the Department of Health and Human Services, said it was possible to address the roots of the addiction crisis while helping people receive the medications they need.
“It is a false choice to say we can only limit opioid use disorder, or addiction, or have pain control,” he said.
Overall, the guide casts the decision to taper as an individualized one that prescribers and patients should reach together. Tapers may need to go slowly and their effects should be reviewed throughout the process. Patients need to have their concerns addressed, the guide stresses. It even suggests clinicians reiterate to patients that, “I’ll stick by you through this,” and to offer other forms of support.
Successful tapers to lower dosages can lead to improvements in sleep, mood, and overall daily function without leading to a resurgence of pain, according to the guide. But it also describes the risks of rapid tapering on the first of its six pages. It warns that doing so can induce withdrawal symptoms and recommends that abrupt dose reductions only happen when there are concerns about impending overdoses or other life-threatening issues. It also provides examples of when patients and prescribers should consider tapering, including when the drugs appear not to be working for pain control, or when the patient has side effects or starts taking certain other types of medications, including benzodiazepines.
On the call with reporters, Dr. Deborah Dowell of the Centers for Disease Control and Prevention said there are not specific targets that dose reductions should try to hit. Instead, patients and clinicians should find doses where the benefits of opioid use outweigh the risks.
“Tapering success does not mean getting down to zero or to any particular dose,” Dowell said.
While experts widely agree that overprescribing contributed to the opioid addiction crisis, there’s been an ongoing debate about how insistently to pursue tapers for chronic pain patients. Many who have been on opioids for years have grown dependent on the drugs, and it can be difficult for them to come off the medications. It can also be hard to distinguish whether tapering is leading to a return of pain or temporary symptoms of withdrawal.
While some experts have preached caution — in some cases advocating leaving patients at high doses if tapering could throw off their lives — others argue that leaving patients on these doses for long periods is bad medicine. Higher dosages of opioids are associated with overdose risk, and there is evidence that chronic opioid use can leave people more sensitive to pain and contribute to anxiety and depression.
Much of the debate has focused on a set of 2016 prescribing recommendations from the CDC. The guidelines were a measured set of proposals, including that clinicians treating chronic pain try other therapies before opioids and prescribe only the lowest effective dose and duration of the drugs. The CDC suggested that prescribers “work with patients to taper opioid to lower dosages or to taper and discontinue opioids” in cases where the harms of taking the drugs outweigh the benefits.
But after the guidelines came out, insurers, pharmacies, states, and law enforcement agencies started cracking down on high prescribing, often pointing to the guidelines as the source of their policies. Clinicians grew even more nervous about treating chronic pain patients, advocates said, and sometimes dismissed their patients.
Earlier this year, the authors of the CDC guidelines wrote in a follow-up paper that their recommendations had been misapplied. They said that some agencies and companies used the guidelines incorrectly to justify an “inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drugs dosages.”
Dowell (who is one of the authors of the CDC guidelines), Giroir, and Dr. Wilson Compton of the National Institute on Drug Abuse also wrote a piece in JAMA Thursday describing the tapering guide. In it, they write that “clinicians have a responsibility to provide care for or arrange for management of patients’ pain and should not abandon patients.”
They add: “For patients who are unable or unwilling to taper and who continue receiving high-dose or otherwise high-risk opioid regimens … close monitoring and mitigation of overdose risk are recommended.”