Moving On From Opioids - Tapering and Cessation

Author: Jennifer M. Hah

Dr. Hah: There is not very great evidence in terms of what the outcomes are for long-term opioid therapy for chronic non-cancer pain. That's not to say that it's good or bad. But the question is how do we prescribe opioids, how do we do it safely, and when patients express interest in tapering their opioids, how do we jump on that opportunity and lead them to other therapies that may be more effective.

Dr. Prasad: We just want to remind clinicians that it's an interdisciplinary approach that's going to help people the most, especially when you're weaning people off of medications. If the opiates have been the primary tool that they've used to manage their pain and you're taking that away, you need to give them other tools, not necessarily other drugs but other non-pharmacologic treatment modalities. One of the biggest challenges to tapering is fear. Patients become very reliant on the medications. They become dependent. Dependence isn't the same thing as addiction. When people are very psychologically dependent, it's challenging to get them to accept that there can be another possibility of managing their pain. In our inpatient program, we wean them using a dosage blinded pain cocktail, so they're not aware of how fast the changes are occurring and they're concurrently working with physical therapy, occupational therapy and psychology to help them develop other tools to manage their pain. When you're inheriting a new patient, it's a great opportunity for education. The patient has learned one certain way of how to manage their pain with the clinician that they've worked with before. Now you have a wonderful opportunity to re-educate the patient on different ways of managing pain.

Dr. Hah: I think one of the main factors is gauging what the patient finds as motivation for coming off of their opioids. If a patient appreciates the risks of staying on these prescription opioids long term—opioid misuse, overuse, addiction, not to mention tolerance or withdrawal—then engaging in an open dialogue with their provider to place those goals at the forefront is really important. I think that when the message comes from the provider in a more punitive way that's really not as effective. I think we can learn a lot from our addiction medicine colleagues in terms of this motivational approach and really gauging where patients are along those lines. Once patients find inner motivations and reasons for coming off of their opioids, it's usually fairly self-directed. But it is an interdisciplinary undertaking. It involves medications. It involves any other interventions that the pain specialist could do concurrently, definitely heavily reliant on psychological approaches and frequent contact with the patient. And instilling a sense of self-management and self-care, having the patient take ownership for their health in general is extremely important to this process.

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