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      Opioid Tapers Have Vital Mental Health Benefits for Patients... if Done Correctly

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      There’s no denying the mental health benefits that slow opioid tapers provide to patients, according to a Colorado opioid and pain control expert. In particular, he says, slow-tapering patients have an extremely low risk of a mental health crisis, suicidal ideation, or suicide attempts.

      'Unanticipated Risks' of Tapering Can Be Averted

      These benefits are an interesting contrast to a recent study by researchers at UC Davis. Published in JAMA, the report emphasizes the potential risks to patients on opioid tapers compared to patients who maintain their opioid therapy treatments without tapering.

      tapering-and-mental-health-dr-don-staderAs Donald Stader, a Denver-based emergency physician and opioid consultant, explains, by extending tapers over say a one- or two-year period, unstable patients give their bodies time to resume the reproduction of their own natural dopamine and endorphins – resuming a process that was essentially hijacked by opioids' highly addictive properties when they were first introduced into a patient’s system.

      What happens is that the body and the brain become dependent on opioids, he says, “meaning that it's dependent on opioids to provide dopamine, it's dependent on opioids to provide endorphins, it's dependent on those opioids for those neurochemicals that prevent anxiety, depression, and pain, etc. And if you take people off too quickly, their levels of dopamine and endorphins plummet. And then that person oftentimes experiences a mental health emergency or suicidality that's based on neurochemical shifts that happen as you withdraw the opioid.”

      “What that tells you is that opioids are not just pain relievers,” he continues. “Opioids have a profound, profound effect on people's emotional states. And the power of opioids is often very, very underappreciated by physicians and patients themselves. And so, as you withdraw that opioid, you do risk that crisis if that person isn't able to mount enough dopamine, serotonin, norepinephrine – all those other things that actually help balance your brain chemistry.”

      He acknowledges that such outcomes are an “unanticipated risk” of opioid tapering, but that for many patients there is also “an unanticipated danger of being placed on these medicines in the first place.”

      No Easy Decision for Mental Health Providers

      In the short term, opioids can be very powerful antidepressants that help patients chemically cope with their issues. In the long term, of course, there’s always concern about the fallout from prolonged opioid addiction. Mental health prescribers are often forced to walk a fine line when weighing the benefits vs. the harm of opioid medication. But as Stader explains, even when there’s a purpose behind the prescription, there’s also often a price to be paid:

      “The people who get into the most problems with opioids are people who aren’t just chemically coping with pain, but people who are chemically coping with depression, anxiety, and past trauma. And that's why things like sexual abuse, childhood abuse, etc., are very, very potent predictors of who develops opioid addiction.”

      In his practice, Stader says there have been many instances when he’s asked patients why they started using opioids in the first place. Examples of the kinds of answers he often hears include:

      • “Because it made me forget about the fact that my dad beat me.”
      • “It made me forget about the fact that I was sexually molested as a child, and when I took those drugs, all that stuff just melted away.”

      The point being, he says: Opioid use is not just about getting high or “unmitigated hedonism and enjoyment.” It’s frequently about treating profound, unresolved psychological pain that can ultimately lead to continued and harmful opioid dependency.

      “Opioids, oftentimes, are about relief," says Stader. "Relief from anxiety, relief from depression, and relief from trauma. And people get down into that rabbit hole where they’re dependent on that drug for finding that relief rather than actually addressing it in a more kind of substantive and productive way.”

      Avoid Opioids as First Prescription Option

      substance abuse ehr system informationFive years ago, Stader was on the tail end of a shift when a woman in severe opioid withdrawal was rushed into the emergency department of the suburban Denver hospital where he worked. Later, after reviving the woman with a dose of Narcan, Stader asked her how she’d become addicted.

      She told him a doctor had prescribed Percocet for a simple ankle sprain, sending her life as a college student into a tailspin of drug addiction, homelessness, and prostitution. For Stader, a liberal prescriber of opiates at the time, it was a practice-changing encounter. Like so many other providers, he was a product of the times. But times are changing, and Stader is now an active leader of that change through programs and projects that include:

      • Chairing a committee that established opioid prescribing and treatment guidelines for Colorado (and that have since been adopted in several other states)
      • Compiling a comprehensive list of opioid prescribing guidelines that include alternative medications for specific surgeries, injuries, and conditions, etc.
      • Founding an opioid consulting firm
      • Founding the Colorado Naloxone Project
      • Assuming the role of medical director of an opioid stewardship program

      The message he emphasizes today is this: “From here on out, we should not be using opioids as first-line therapy for pain. Period.”

      For Stader, his activism isn’t just a response to that one patient who changed his way of thinking about opioids but to the hundreds of thousands of patients over the course of the 1980s, 1990s, and early 2000s who were downing opioids “like hotcakes” and are now on chronic opioid regiments.

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      These legacy patients – patients who have been on high-dose opioids over an extended period of time – require patient-centered, individualized care. And depending on the patient, that might mean tapering them off their opioids altogether, or it might mean maintaining them on their current opioid therapy. 

      The objective, says Stader, is to "evaluate whether chronic opioids are going to be the best thing for long-term health and long-term functionality – or whether the best thing to do for the long-term would be to come off the opioids. And that's a decision that has to happen on an individualized basis with the doctor with the patient."

      But if the decision is to take them off of opioids, that doesn’t mean subjecting them to an expedited tapering program.

      “The wrong thing to do for those patients is to tell them all, ‘Hey, no more opioids for anyone.’ Because you’ll have a lot of people who commit suicide, who have worse outcomes, who feel a loss of autonomy while they’re in the medical system. And all of those are practice failures, right?”

      “I think that oftentimes patients are surprised by how much they benefit when they come off opioids. And as physicians, we need to actually learn the skill of how to deprescribe – and deprescribe and taper in a way that doesn’t harm some of those patients who were originally put on very high doses.”

      Resources

      “There's a growing body of literature that suggests that tapering slowly whenever possible is likely better for patients," says Stader. "That's what the evidence is starting to show, (that) slow tapering oftentimes produces less risk than rapid taper.”

      Below are some resources to get you started:

      The InSync EHR Software Helps your Practice to be more effective in the Battle Against Opioid Addiction 

      As a  leader in behavioral health EHR software, InSync Healthcare Solutions offers features that effectively equip practices in their treatment of patients with substance use disorder and opioid use disorder, including:

      • Substance abuse software that facilitates the planning and implementation of effective treatment plans for substance use disorder treatments
      • A full pharmacological history along with drug allergies via fully integrated e-prescription software
      • A fully integrated EMAR system to allow the safe and scheduled dispensing of medications for inpatient care

      As the choice for thousands of mental health providers across all 50 states, The specialized InSync EHR system includes everything from group therapy scheduling and group notes to telehealth, e-Prescribing, eMAR, custom forms, and more.

      schedule a demo with insync healthcare solutionsAnd with CCBHC-specific technology, we can streamline workflows, save time and minimize the chances of human error, all while scaling alongside your enterprise-level facility.

      For a closer look at how our interoperable and mobile-friendly software can increase efficiencies and streamline workflows in your practice, schedule a demo now with one of our experts. We're happy to answer questions and explain how we can customize our system to be what you need it to be. 

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