The US Department of Health and Human Services (HHS) released the Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics, which identifies best practices for how and when to taper or discontinue opioid use in pain management patients.
This guide emphasizes that the opioid dosage thresholds recommended by the Centers for Disease Control and Prevention (CDC) are only provisional and should not be used to directly inform decisions on dose reduction or discontinuation of opioid use. Instead, HHS recommends assessing each patient individually and coordinating with other providers in the healthcare system to identify all risks associated with continued opioid use, including comorbid illnesses, mental health concerns, and contraindications with other prescribed drugs. While late-stage cancer treatment and end-of-life care can be considered sufficient grounds for long-term opioid therapy, HHS recommends that clinicians consider initiating a taper if the patient:
- is no longer in pain;
- wants to stop treatment;
- is no longer experiencing noticeable benefits from opioid use;
- is experiencing severe side effects; or
- is at risk of drug dependence.
If a clinician initiates a taper, HHS also recommends incorporating nonpharmaceutical interventions (e.g., physical therapy), as well as nonopioid analgesics (e.g., non-steroidal anti-inflammatory drugs like ibuprofen) into the patient’s pain management regimen to ease their transition.
Furthermore, this guide suggests that a slow taper is often in the best interest of the patient, as tapering the dosage too quickly might lead to exacerbation of pain, acute withdrawal symptoms, increased psychological agitation, thoughts of suicide, and pregnancy complications, all of which might incite patients to seek illicit opioids. However, the guide also indicates that faster tapering or discontinuation might be warranted if the patient is at significant risk of life-threatening complications, such as opioid overdose.
If a clinician observes that a patient is unwilling or unable to reduce their opioid use, it is recommended that they assess the patient for signs of substance use disorder. If such risk factors are identified, HHS suggests offering medication-assisted treatment (e.g., buprenorphine) to balance pain management and tapering in a more controlled manner. HHS also recommends that clinicians mitigate overdose risks by providing overdose-reversal medication such as naloxone, and overdose prevention education.
HHS published this guide following concerns that a 2016 CDC guide, Guideline for Prescribing Opioids for Chronic Pain, which did not include specific recommendations for dose reduction or discontinuation, was being misapplied by clinicians and harming pain-management patients.