Recently, the United States Department of Health and Human Services (HHS) issued new guidance on appropriate tapering or discontinuation of long-term opioid use. The new guide, the HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics, serves as advice to clinicians who are contemplating or initiating a change in opioid dosage for a patient.
The Guide is compiled using published guidelines and practices endorsed in peer-reviewed literature and lists issues clinicians should consider before making a change in a patient’s chronic pain therapy, including shared decision-making with the patient; issues clinicians should consider when initiating the change; and issues the clinician should consider as a patient’s dosage is being tapered, including the need to treat symptoms of opioid withdrawal and providing behavioral health support.
According to a press release issued by HHS announcing the new Guide, Clinicians have a responsibility to coordinate patients’ pain treatment and opioid-related problems. While there may be certain situations where a reduced opioid dosage may be indicated in joint consultation with the care team and the patient; however, HHS does not recommend opioids be tapered rapidly or discontinued suddenly due to the significant risks of opioid withdrawal, unless there is a life-threatening issue confronting the individual patient.
HHS recommends that providers and patients work together to come to a decision to reduce opioid dosages. The guide also provides examples of when providers should consider tapering patients off the drugs; for example, clinicians should consider reducing a patient’s opioid dosage if the drug is not controlling the patient’s pain, if a patient is experiencing side effects, or if a patient begins to take certain new medications, including benzodiazepines.
The guide notes that providers “should never abandon” patients who are tapering off of opioids. While the guide denotes that opioid doses are generally decreased by 5% to 20% a week, Deborah Dowell, the chief medical officer of CDC’s division of unintentional injury prevention, said there are no specific targets that providers should strive to reach when reducing a patient’s opioid dosages. Instead, providers and patients should focus on finding dosage levels where the benefits outweigh the risks.
Tapering is not idea for every patient, however, as the new HHS guide does acknowledge that there may be instances where abruptly taking a patient off of opioids is acceptable, such as when the provider has a concern about a potential overdose or other life-threatening side effects.
“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, M.D., assistant secretary for health. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”
These new recommendations are a stark contrast to guidelines issued by the Centers for Disease Control and Prevention in 2016, which focused on cautious prescribing and emphasized that opioids were not to be considered a first-line treatment or appropriate for routine therapy. Many clinicians took issue with those guidelines, saying they went too far and resulted in unintended consequences, which hurt patients.