By Jordon L. Newmark, MD
To achieve positive and safe outcomes with opioid therapy, it is essential to set realistic treatment expectations with the patient. A crucial and sometimes sensitive part of those expectations relates to opioid weaning and discontinuation. Ideally, discussions between provider and patient about when and how to wean the patient off opioids should occur during initiation and maintenance of opioid treatment. This makes the eventual weaning process easier for everyone involved in the care of the patient.
When to Wean
Providers should consider an opioid wean when the risks associated with treatment begin to outweigh the benefits.1 A patient reporting a lack of improvement in pain or function, signs of opioid abuse, nonadherence, severe adverse effects, or unexpected and confirmed results on urine drug tests are among reasons to potentially discontinue the drug.2
During the maintenance phase of opioid therapy, several monitoring tools may help providers determine if favorable outcomes are outweighing the possible dangers, including aberrant behaviors. The US Food and Drug Administration’s “Risk Evaluation and Mitigation Strategies” and the Centers for Disease Control and Prevention’s “Guideline for Prescribing Opioids for Chronic Pain” both suggest a number of methods and instruments.3,4
One that is commonly used and easy to administer is the Pain Assessment and Documentation Tool (PADT).5 This instrument includes 4 domains: (1) pain relief, (2) patient functioning, (3) adverse events, and (4) drug-related behaviors. These items are also known as the “4 A’s”: (1) analgesia, (2) activity level, (3) adverse events, and (4) aberrant behaviors.
Nonadherence to an opioid treatment plan is a common trigger for initiating a wean.6 Reasons for patient under-usage include fear of addiction, side effects, and complexity of the medication regimen. This type of nonadherence leads to excessive pill volumes, and can pose safety concerns not only to the patient but also to family members and friends, through theft, diversion, or accidental ingestion. Opioid over-usage also creates a safety threat and may be associated with use of opioids for other symptoms (i.e., chemical coping), noncompliance, misuse, abuse or addiction.
Once the provider determines that an opioid “exit-strategy” wean is warranted, he or she should initiate a compassionate and empathic discussion with the patient. The provider should make clear to the patient that weaning does not represent abandoning pain care, but that the patient is not a suitable candidate to continue an opioid regimen. A number of resources exist to assist both the patient and provider during weaning, including addiction medicine consultation, pain psychology, and mental health services. It is also important to empower the patient to develop an emotional support network of family, friends, and others to help during the process. If it is confirmed that no opioid is present and there are no signs or symptoms of withdrawal, a wean is not necessary, and abruptly discontinuing medication is more likely in order.
Three potential pathways exist in constructing an opioid wean strategy, each based upon the patient’s current response to opioid-related treatment (Figure 1).2 Safe and effective opioid weaning should balance medication down-titration with symptoms of withdrawal. Although uncomfortable, withdrawal from opioids is rarely life threatening. Abruptly stopping some medications, such as benzodiazepines, may, in fact, be life threatening.7 The literature varies on recommendations on tapering schedules, with some recommending 20% to 50% per week as tolerated.8
The patient’s condition should be monitored frequently during weaning, with follow-up clinical examinations. These office visits allow for the use of provider-administered, quantitative withdrawal scales, such as the Clinical Opiate Withdrawal Scale (COWS) or the Clinical Institute Narcotic Assessment (CINA). Both subjective and objective signs and symptoms of opioid withdrawal exist, and the two should be distinguished from one another (Table 1). Therefore, depending on how the subjective items are measured, it is possible to obtain a range of scores. A number of medications and other strategies exist to mitigate withdrawal, such as ondansetron for nausea, loperamide for diarrhea, and clonidine for pain and anxiety associated with autonomic hyperactivity.2 Nonpharmacological approaches are also available, such as mindfulness, acupuncture, and hypnosis.2
From a public health and safety standpoint, proper disposal of unused opioid medications is essential and often not discussed. The Drug Enforcement Agency and Food and Drug Administration offer a number of appropriate strategies.9-11
- Lembke A, Humphreys K, Newmark J. Weighing the risks and benefits of chronic opioid therapy.Am Fam Physician. 2016;93(12):982-990.
- Mackey S, Lahidji S, Schonwald G, Newmark J. Safe Opioid Prescribing and Risk Evaluation and Mitigation Strategies (REMS) Online CME Course. Stanford University School of Medicine. November 2, 2015. Available at: http://online.stanford.edu/course/opioid-prescribing-cme-sp2014. Accessed August 11, 2016.
- Food and Drug Administration. Approved Risk Evaluation and Mitigation Strategies. Available at: http://www.accessdata.fda.gov/scripts/cder/rems/. Accessed August 11, 2016.
- Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain. Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed August 11, 2016.
- Passik SD, Kirsh KL, Whitcomb L, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy.Clin Ther. 2004;26(4):552-561.
- Fishman SM, Wilsey B, Yang J, Reisfield GM, Bandman TB, Borsook D. Adherence monitoring and drug surveillance in chronic opioid therapy.J Pain Symptom Manage. 2000;20(4):293-307.
- Lann MA, Molina DK. A fatal case of benzodiazepine withdrawal.Am J Forensic Med Pathol. 2009;30(2):177-179.
- US Department of Veterans Affairs. Tapering and Discontinuing Opioids. Available at: http://www.healthquality.va.gov/guidelines/Pain/cot/OpioidTaperingFactSheet23May2013v1.pdf. Accessed August 11, 2016.
- Drug Enforcement Administration. Drug Disposal Information. Available at: http://www.deadiversion.usdoj.gov/drug_disposal/index.html. Accessed August 11, 2016.
- Edles A. Opioid disposal: dos and don’ts.Pract Pain Manag. 2012;12(4):17-18.
- Food and Drug Administration. Disposal of Unused Medicines: What You Should Know. FDA.gov. Available at: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm. Accessed August 11, 2016.