Putting Opioids in the Rearview Mirror at AAPM

“The opioid crisis” is a term that has made its way into the public consciousness, and with it has come increased scrutiny, crackdowns, and fear. It’s no surprise, therefore, that finding ways to decrease the quantity of opioids prescribed is at the forefront of many pain medicine physicians’ minds. But what is the safest way to do this while maximizing both patient acceptance and outcomes?

At the 2020 American Academy of Pain Medicine (AAPM) Annual Meeting outside Washington, D.C, Aram Mardian, MD, Beth Darnall, PhD, and Anita Karnik, MD discussed their strategies for optimal opioid deprescribing. They endorse a paradigm shift in pain management from a structural pathology outlook to “whole-person” care that involves not only the biomedical sphere but also the social and psychological spheres. In a 2018 study, Dr. Darnall’s team studied patient-centered prescription opioid tapering in community outpatients. The hallmark of their taper was that it was patient-controlled: among other distinguishing features, patients could pause their taper, the taper was not to a pre-defined opioid dose, and the taper was not unidirectional. The goal was to achieve the lowest comfortable dose over four months. Using their protocol, median opioid doses dropped from a morphine-equivalent daily dose of 288 to 150 in 16 weeks. Dr. Darnall’s recommendations for implementing whole-person pain care in the community included developing specific relationships with community clinicians in order to coordinate care, ensuring that opioid reduction is voluntary, giving patients as much control as possible, actually increasing follow-up and communication with patients during a taper, recognizing that not everyone can taper opioids, and being willing to go back up on doses if a patient is not tolerating lower ones. Coaching for clinicians may be helpful to regulate physicians’ own emotional responses during conversations with patients on opioids. Keys to patient-centered opioid tapering include recognizing that most patients are fearful, explaining the health benefits to the patient of reducing opioids, explaining that the team will partner closely with them, and helping them feel in control.

Dr. Mardian noted that while there is no evidence of long-term benefit or safety with opioid use, there is in fact new evidence of harm and of the absence of benefit when compared to other medications. Factors that increase the risk of adverse outcomes with opioid therapy include medical comorbidities, mental health/substance abuse comorbidities, a recent opioid overdose, non-adherence with opioid safety monitoring, high prescribed opioid doses, and rigid rather than whole-person pain care approaches. 

There is also evidence that dose changes in either direction confer risk. Opioid-exposed patients are fundamentally different from opioid-naive patients, due to physical brain changes caused by long-term opioid therapy. Rigid opioid tapering regimens that do not take into account patient anxiety or a genuine need for analgesia often result in patients being unable to cooperate with a taper and subsequently being discharged for medication non-compliance. However, a whole-person approach includes patient education on the neurobiology of opioids, screening for opioid use disorder (OUD), discussing strategies for improved social engagement, an exercise prescription, pain psychology involvement, and a slow opioid reduction of 2.5 mg oxycodone per day. The concept of “microtapering” was discussed: reduction by half a pill per day every 1–2 months for short-acting opioids, or one of the lowest strength pill per day every 1–2 months for long-acting opioids. These tapers are so slow that physiologically they make little difference; however, the psychological benefits of increasing patient confidence and buy-in can make this approach particularly successful. Included in this strategy is the idea of “the power of the pause,” which can be used when there is diagnostic/therapeutic uncertainty and no imminent risks, and which allows patients to pause their taper and take additional time for the neurobiological changes caused by opioids to adjust, increasing their sense of control and the likelihood that they will continue to participate. The speakers underscored that it is important to recognize when decreasing opioids may actually be higher-risk than leaving doses as is. Even after opioids have been decreased to their lowest effective dose or stopped completely, monitoring of these patients should continue for a minimum of three months afterwards.

Dr. Karnik noted that physiologic dependence must be differentiated from OUD. The former includes tolerance and withdrawal symptoms, but withdrawal lasts no more than a few weeks and it is relatively easy to cease opioid use. Patients with OUD, however, display at least two of nine specific criteria, have persistent withdrawal symptoms, and find it very difficult to stop opioid use. Addiction is defined by the three C’s: Compulsive use, continued use despite Consequences, and use that is out of Control. She recommended using a standardized screening tool such as the Nida Quick Screen to evaluate for OUD rather than relying on clinical judgment alone, due to the risk of bias. OUD must be treated with medications for addiction treatment, and the three currently FDA-approved medications for OUD are buprenorphine, methadone, and naltrexone. While buprenorphine can be used to treat pain without additional training, a DEA waiver and specific CME instruction is required if a clinician prescribes this to treat OUD.

Opioid deprescribing is an important and timely skill in our current climate, but one that is fraught with challenges and uncertainty. Utilizing tools to encourage patients to partner with pain physicians in this endeavor could change the face of the opioid crisis completely, and save lives that are currently on the edge.

Dr. Elizabeth (Lisa) Varghese-Kroll, MD, FAAPMR is a physiatrist and experienced physician advisor with a background in broadcast journalism who is based in the greater Washington, DC area. She is a 2019-2020 Doximity Conference Fellow. Follow her on Twitter at @LisaVKMD.

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