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      Opioid Tapers Are Bound to Backfire if Executed Too Quickly

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      At its best, opioid tapering is a process that can completely ween patients off their highly addictive medication. But at its worst, opioid tapering can leave those same patients in far worse condition than if there’d been no taper at all. Not only can the consequences be dire, but they can also be fatal.

      Rapid Opioid Tapers Can End in Depression or Suicide

      The difference between success and failure is usually the pace with which the dose-reducing exercise of opioid tapering is executed. A slow taper more frequently achieves the desired outcome – either a substantial reduction or the complete elimination of an opioid regimen. Conversely, rapid tapers can result in heightened depression, overdoses, and suicidal tendencies – the exact opposite of what tapers are intended to achieve.

      A team of researchers at UC Davis Health recently examined the potential risks of opioid dose-tapering and found that patients on stable opioid therapy experienced significantly higher rates of overdoses and mental-health breakdowns when their doses were tapered – compared to patients with no dose-reductions at all. The study was published in JAMA in August 2021.

      “(The study) suggests that patients undergoing tapering need significant support to safely reduce or discontinue their opioids,” says Alicia Agnoli, assistant professor of Family and Community Medicine at UC Davis School of Medicine and first author on the study.

      Dr Donald Stader, Opioid tapering expertSome of that support comes from providers like Dr. Donald Stader, an opioid and pain control specialist who also serves as an emergency physician in the greater Denver area.

      Stader told InSync Healthcare Solutions that he has encountered any number of patients on opioid tapers who arrive at the hospital in opioid withdrawal. The reasons for the withdrawals, he explains, generally boil down to two things: 1) A tapering plan that is “too aggressive”, or 2) The patient's prescriber cut off their opioid prescriptions without any tapering program whatsoever.

      “Obviously,” Stader says, “there's a right and wrong way to taper a patient who’s stable on their dose. And definitely, what this study shows is the danger of tapering patients carelessly – or tapering patients and not having the medical knowledge to do it correctly.”

      So, what is the correct way to taper?

      The answer to that question varies by patient, says Stader. In fact, there are certain situations in which a rapid taper is the best available option for saving a patient.

      “If the (prescribed) opioid is starting to have a clear and present risk – a clear and present danger – to the patient, then sometimes you need to move more quickly,” says Stader.

      In some cases, that risk might result from a provider putting a patient on an opioid regimen that puts them in imminent danger of an overdose or other adverse outcomes.

      “The other condition for unilateral tapering is if they have opioid use disorders or opioid addiction, and then you should actually not just rapidly taper, but you should transition that patient to the medications for opioid use disorder, whether that's methadone or Buprenophine,” advises Stader.

      It’s a different story for stable patients who, for example, have been prescribed opioid therapy for chronic pain. For those patients, Stader advises, “the right way” to proceed is:

      • Involve them in shared decision-making
      • Taper them off the opioids as slowly as possible so they don’t experience significant withdrawal
      “We know right now from studies that people with chronic opioid therapy oftentimes will have an improvement of pain once we get them off their medicines, meaning that 85% of patients – once you taper their meds off – either their pain stays the same or they're pain improves. We know that at the end of tapering, oftentimes patients do better. Now, the road that you travel from a high dose of opioid or a stable dose of opioid to no opioid is the thing that determines if your patients do well or do poorly.”

      Dr. Donald Stader

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      Can you properly follow tapering protocols and still have bad outcomes?

      “No matter what you do, the answer is yes,” says Stader. “The likelihood of having a bad outcome depends on your protocol and it depends on how closely you’re monitoring that with your patients. So, is there a potential for a bad outcome? In medicine, even the most routine of surgeries or procedures has that potential. But how you mitigate those risks and decrease those risks really is what matters and makes it so that your bad outcome is as rare as humanly possible.”

      Despite the inherent risks associated with tapering, says Stader, there are steps you can take to minimize those risks and, better yet, affect successful outcomes, including:

      • Closely monitor your patient
      • Be aware of the potential risks
      • Actively work with the patient to mitigate those risks

      Although each of these steps is supported by the UC Davis researchers, professor Joshua Fenton, senior author of the study, echoes Stader by voicing serious concerns about what providers are doing to ensure their patients’ safety. “I fear that most tapering patients aren’t receiving close follow-up and monitoring to make sure they’re coping well on lower doses,” he says.

      Guidelines by The Centers for Disease Control and Prevention discourage higher doses of opioids in managing chronic pain – instead, recommending dose-tapering when it’s determined that the harms of continued therapy outweigh the considered benefits to the patient. For some patients on stable opioid therapy, however, dose-reducing tapering has led to increased pain, symptoms of opioid withdrawal, and depression. It’s a dilemma that puts prescribers in a difficult position, according to Agnoli.

      “There are conflicting desires of ameliorating pain among patients while reducing the risk of adverse outcomes related to prescriptions,” she says.

      The study examined the enrollment records and medical and pharmacy claims of more than 113,000 patients on stable higher opioid doses – the equivalent of at least 50 morphine milligrams per day over a one-year period, plus follow-ups for at least two months.

      Researchers focused on emergency department visits or inpatient hospital admissions for any of the following:

      • Drug overdoses
      • Alcohol intoxication
      • Drug withdrawal
      • Mental health crisis events such as depression, anxiety, or suicide attempts

      substance abuse ehr system informationThe researchers also compared the outcomes for two sets of patients: Those whose opioid doses had been tapered and those whose doses hadn’t been tapered. Among those who had tapered, researchers found a 68% increase in overdose events and double the number of mental health crises compared to those who hadn’t tapered.

      Those statistics alone might be enough to dissuade providers and patients from attempting a taper. But should they? 

       

      Is The Study Sending a Wrong Message?

      The results of the UC Davis study are not ground-breaking, says Stader. Although the study was conducted with a much larger patient population than an earlier study, the conclusions for both are essentially the same: “That rapid tapering incurs a significant amount of risk in terms of increased suicidality or mental health crises,” he says.

      Despite one study validating the other, Stader expresses concern that the UC Davis study is sending the wrong message – that everyone already on chronic opioid therapy should remain on chronic opioid therapy.

      "That's actually the wrong message from this. The message should be that you should look at every patient individually. We know there's benefits to opioid tapering in a large number of patients. And how you get from point A to point B should be slow and steady, and you should be looking at these different perspectives as you taper them.”

      Dr. Donald Stader

      “This is just a really complicated piece of medicine right now,” he continued. “And I think that this study that came out in JAMA was just a good reminder for providers that there are risks not only to starting an opioid but to stopping an opioid.”

      Help is Available

      If you're struggling with addiction call the SAMHSA national hotline at 1-800-662-HELP (4357). Service through this number is free of charge and there is someone to help 24/7 365 days a year. If you prefer not to speak with anyone you can still visit the SAMHSA treatment center location finder by using this Behavioral Health Treatment Services Locator

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