Opioid Tapering for Chronic Opioid Users: Parts I and II

1. Opioid Tapering for Chronic Opioid Users: Parts I and II Corey J. Hayes, PharmD, PhD, MPH Assistant Professor Departments of Psychiatry and Biomedical Informatics University of Arkansas for Medical Sciences College of Medicine Research Health Scientist VA HSR&D Center for Mental Health and Outcomes Research Central Arkansas Veterans Healthcare System Primary Email: cjhayes@uams.edu

2. Part I: CDC Guidelines for Prescribing Opioids for Chronic Pain and Tapering Logistics

3. CDC Guidelines: What They Are and Are Not • Are Recommendation for: • Primary Care Providers • Family medicine, Internal medicine • Treating patients >18 years with chronic pain • Pain longer than 3 months or past time of normal tissue healing • Outpatient settings • Are Not: • Guidelines on Treatment of Cancer-Related Pain • End of Life Care • Palliative Care

4. 12 Recommendations for 3 Areas • Determining When to Initiate or Continue Opioids for Chronic Pain • 3 Recommendations • Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation • 4 Recommendations • Assessing Risk and Addressing Harms of Opioid Use • 5 Recommendations

5. Recommendation 1 • Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred • Non-Pharm Therapy: exercise or cognitive behavioral therapy (CBT), weight loss, interventional procedures • Non-Opioid Pharm therapy (NSAIDs, acetaminophen, anticonvulsants, certain antidepressants) • Consider opioid therapy only if expected benefits for both pain and function > risks • If opioids are used, combine with non-pharmacologic therapy and non-opioid pharmacologic therapy • (Recommendation category: A, evidence type: 3)-may change with new studies

6. Recommendation 2 • Before starting, establish realistic treatment goals for pain and function: • Determine how effectiveness will be measured • Establish treatment goals for pain relief AND function • Continue opioid therapy only if there is clinically meaningful improvement in pain and function > risks: • Use PEG (Pain, Enjoyment of Life, General Activity, each 0-10) Assessment Scale, 30% change is clinically meaningful • (Recommendation category: A, evidence type: 4)

7. PEG Scale Krebs et al. “Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference.” J Gen Intern Med. 2009 Jun; 24(6): 733–738.

8. Recommendation 3 • Before starting and periodically: • discuss risks and realistic benefits of opioids • patient and clinician responsibilities for managing therapy • This could look like discussions of: • serious and common adverse effects • increased risks of overdose with high doses and taking with other drugs and alcohol • reassessment of effectiveness • use of PDMP and UDS • risks to family members and individuals in the community • (Recommendation category: A, evidence type: 3)

9. Area 2 Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

10. Recommendation 4 • When starting opioid therapy for chronic pain prescribe IR opioids and not ER/LA opioids: • Higher risk than initiating on IR opioids • No evidence that ER/LA is more effective or safer • Avoid IR and ER/LA combos-higher risk with no benefit • Methadone and Fentanyl only used by experience prescribers • (Recommendation category: A, evidence type: 4)

11. Recommendation 5 • Prescribe the lowest effective dosage • Carefully reassess individual benefits/risks when≥50 MME/day and: • Increase frequency of follow-up • Consider offering naloxone • Avoid increasing dosage to ≥90 MME/dayor carefully justify • (Recommendation category: A, evidence type: 3)

12. Recommendation 6 • With acute pain, prescribe the lowest effective dose of IR opioids, no ER/LA opioids • Prescribe no greater quantity than needed, no “just in case” • 3 days or less will often be sufficient; more than 7 days will rarely be needed • This does not address post-surgical pain • “Opioid treatment for post-surgical pain is outside the scope of this guideline but has been addressed elsewhere” • (Recommendation category: A, evidence type: 4)

13. Recommendation 7 • Evaluate benefits/harms: • within 1-4 weeks of starting or increasing the dose • at least every 3 months thereafter • If benefits < harms, optimize other therapies andtaper opioids • (Recommendation category: A, evidence type: 4)

14. Recommendation 7 Continued • At follow up, ask 4 things: • 1. Do opioids continue to meet treatment goals? • 2. Are there common or serious adverse events or early warning signs? • 3. Do benefits > risks? • 4. Can opioid dosage can be reduced or opioids can be discontinued? • Instancing when to really consider tapering (10% per week): • 1. no sustained clinically meaningful improvement in pain and function • 2. opioid dosages >50 MME/day without evidence of benefit • 3. concurrent benzodiazepines that can’t be tapered off • 4. patients experience overdose, other serious adverse events, warning signs

15. Area 3 Assessing Risk and Addressing Harms of Opioid Use

16. Recommendation 8 • Incorporate strategies to mitigate risk • Risk mitigation tips: • Avoid opioids with patients with sleep disorders • Use caution in renal or hepatic insufficiency or >65 years of age • Adequately treat MH disorders • Screen for SUDs and Developing Risk (Opioid Risk Tool, Brief Risk Interview, etc) • Consider offering naloxone when certain factors arise: • history of overdose or SUD • higher opioid dosages (≥50 MME/day) • concurrent benzodiazepine use • (Recommendation category: A, evidence type: 4)

17. Recommendation 9 • Review the PDMP data • What to look for in PDMP data review: • receiving other opioids • dangerous combinations • How often to review PDMP data: • when starting opioids • with every prescription or up to every 3 months • If misusing, do not dismiss patient-offer lifesaving info and interventions • (Recommendation category: A, evidence type: 4)

18. Recommendation 10 • When prescribing for chronic pain, use UDS before starting opioids and at least annually • Before ordering UDS: • explain to patients that testing is intended to improve their safety • explain expected results • ask patients whether there might be unexpected results • Verify unexpected, unexplained results using specific test • Immunoassay is typically followed by GC/MS if positive • Do not dismiss patients from care based on a UDS result • (Recommendation category: B, evidence type: 4)

19. Recommendation 11 • Avoid prescribing opioids and benzodiazepines concurrently whenever possible • Taper Benzos gradually • Offer evidence-based psychotherapies for anxiety: • 1. CBT • 2. specific anti-depressants approved for anxiety • 3. other non-benzodiazepine medications approved for anxiety—Buspar takes time • (Recommendation category: A, evidence type: 3)

20. Recommendation 12 • Offer or arrange evidence-based treatment for patients with opioid use disorder • Assess for OUD using DSM-5 criteria. 11 criteria and need 2 of the 11--not both tolerance and withdrawal • If present, offer or arrange MAT and behavioral therapies: • Buprenorphine • Methadone maintenance therapy • Oral or long-acting injectable formulations of naltrexone (for highly motivated non-pregnant adults) • (Recommendation category: A, evidence type: 2)

21. CDC Guideline Mobile App

22. Tapering Logistics

23. Three Main Resources: CDC, Mayo Clinic, and VA • https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf • https://www.mayoclinicproceedings.org/article/S0025-6196(15)00303-1/fulltext • https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

24. When should I consider tapering for my patient according to CDC? • Patient does not have a clinically meaningful improvement in pain and function (e.g., at least 30% improvement on the 3-item PEG scale) • is on dosages ≥ 50 MME/day without benefit or opioids are combined with benzodiazepines • shows signs of substance use disorder (e.g. work or family problems related to opioid use, difficulty controlling use) • experiences overdose or other serious adverse event • shows early warning signs for overdose risk such as confusion, sedation, or slurred speech https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

25. When should I consider tapering for my patient according to VA? https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

26. When should I consider tapering for my patient according to Mayo Clinic?

27. Screen/maximize treatment before tapering: • Mental Health Disorders • One study showed post-tapering depression scores to be the sole predictor of relapse • OUD and other SUDs • “Moral Injury” (Inner Conflict) • Central Sensitization (e.g. fibromyalgia, chronic headaches) • Medical complications (e.g., lung disease, hepatic disease, renal disease, or fall risk) • Sleep disorders including sleep apnea https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf http://www.med.umich.edu/1info/FHP/practiceguides/pain/Opioid.Taper.Mayo.pdf

28. How to Taper • Go Slow-10% per week or slower • Consult-specialists needed • Support-naloxone, MH provider • Encourage-inform patient that most, over time, have improved function https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

29. Use the Following Strategies in Tapering: • Discussion • Ask about Goals • Education https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

30. Discussion • Listen to the patient’s story • Let the patient know that you believe that their pain is real • Include family members or other supporters in the discussion • Acknowledge the patient’s fears about tapering [use Motivational Interviewing (MI) techniques] https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

31. Ask about Goals • Draw out their goals for life (not just being pain-free) • Have the patient fill out the Personal Health Inventory (PHI) • https://www.va.gov/PATIENTCENTEREDCARE/docs/Personal-Health-Inventory-final-508-WHFL.pdf • Ask how we can support them during the taper https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

32. Educate the Patient • Offer physical therapy and Complementary and Integrative Health (CIH) • acupuncture, meditation, yoga • Offer non-opioid pain medications • Provide opioid overdose education and prescribe naloxone to patients at increased risk of overdose • can lose tolerance in a week • at risk of an overdose if they resume their original dose https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

33. https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdfhttps://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

34. Patient Follow Up https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

35. General Approach • Determine patient’s total amount of opioid patient is currently taking every 24 hours • Use conversion chart/app to convert from opioid dose patient is currently taking to morphine equivalent • If converting from parenteral dosage form, convert to parenteral morphine first then from parenteral to oral morphine • Use conversion chart/app to convert from oral morphine equivalent to dose of desired opioid • Decrease total daily dose by up to 50% - 75% to account for incomplete cross tolerance between opioids

36. Equianalgesic Chart* (example) *Compiled from Johns Hopkins opioid program (hopontheweb.org) and CMS (https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Opioid-Morphine-EQ-Conversion-Factors-March-2015.pdf)

37. Opioid Tapering Tools • Guides or Toolkits: • https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf • https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf • http://www.partnershiphp.org/Providers/HealthServices/Documents/Managing%20Pain%20Safely/TAPERING%20TOOLKIT_FINAL.pdf • Templates or Opioid Tapering Agreements: • https://thewellhealth.ca/wp-content/uploads/2018/03/20180305-Opioid-Tapering-Tool-Fillable.pdf • http://www.med.umich.edu/1info/FHP/practiceguides/pain/Opioid.Taper.Mayo.pdf • http://www.rxfiles.ca/rxfiles/uploads/documents/opioid-taper-template.pdf • Calculators: • https://www.hca.wa.gov/search/site/tapering%20calculator?section=%2A • “Slow and Steady Wins the Race” • https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2672574?resultClick=1

38. “Slow and Steady Wins the Race” • “Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain” May 2018 JAMA Intern Med. • Pain Clinic • Of 110 eligible patients, 82 agreed to taper after education (75%) • Tapering over 4 months, not necessarily discontinuing • Opioid dosages were reduced up to 5% through up to 2 dose reductions in month 1 • to minimize negative physical and emotional response, withdrawal symptoms, and to facilitate patient confidence in the process. • In months 2 to 4, patients were asked to further reduce use by as much as 10% per week but were tailored https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2672574?resultClick=1

39. “Slow and Steady Wins the Race” • Demographics: 51 y/o, 60% female • 31 of 82 did not complete a 4 month f/u survey • Marijuana use positively correlated with study completion • Median MEDD for the patients went from 288 to 150 • Neither pain intensity nor pain interference increased https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2672574?resultClick=1

40. “Slow and Steady Wins the Race” https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2672574?resultClick=1

41. Questions?

42. Part II: Withdrawal and Patient Cases

43. Progression of Withdrawal Symptoms https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

44. https://www.mayoclinicproceedings.org/article/S0025-6196(15)00303-1/pdfhttps://www.mayoclinicproceedings.org/article/S0025-6196(15)00303-1/pdf

45. 5-12=Mild; 13-24=Moderate; 25-36=Moderately Severe; >36=Severe Withdrawal https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf http://www.med.umich.edu/1info/FHP/practiceguides/pain/Opioid.Taper.Mayo.pdf

46. Withdrawal Symptom Treatment https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

47. Withdrawal Symptom Treatment https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

48. https://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/tapering-resource.pdfhttps://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/tapering-resource.pdf

49. http://www.med.umich.edu/1info/FHP/practiceguides/pain/Opioid.Taper.Mayo.pdfhttp://www.med.umich.edu/1info/FHP/practiceguides/pain/Opioid.Taper.Mayo.pdf

50. Post-Acute Withdrawal Syndrome (PAWS) • Not an official diagnosis • Cluster of ongoing withdrawal symptoms, mostly psychological and mood-related, that can continue after acute withdrawal symptoms have gone away • Typical symptoms: • Cravings • Exhaustion • Cognitive Impairment • Stress Sensitivity https://www.hazeldenbettyford.org/articles/carty/post-acute-withdrawal-syndrome https://americanaddictioncenters.org/withdrawal-timelines-treatments/post-acute-withdrawal-syndrome/