1. Tapering Opioids (1) C.L.I.P.S.
Who Should be weaned or tapered?
Known/Documented Abuse or Diversion (early refills, lost/stolen meds, escalating dose requests, ED visits, Hx of substance abuse)
Patients who have overdosed
Patients who have medical complications of meds (Endocrine - hypoT, OSA, EKG changes, polypharmacy, increasing age)
Psychosocial risks – Depression, relationship issues, cognitive decline
Functional decline – disability, falls, MVA, unable to manage life/health
Patients who are over 120 MED (maybe >90 MED per CDC)
When Opioids are doing more TO patient than FOR patient (AR)
Who should not be tapered?
Acute fractures, post op patients
Opiate use disorder (see MAT CLIP), careful with methadone due to long T½
Palliative Care patients
Pregnant patients (see special populations CLIP)
Unstable psych patients without multidisciplinary approach/plan
What is the goal of tapering
Increase safety (“Do No Harm”)
Decrease unintentional overdose and death
Improve function
What to expect
Patient will be upset & may take it out on you
Have a game plan (pregame with attending)
Warm Handoff with BH? Clinic manager? Attending?
Who should be considered for opioid taper? When?
Every Patient, Every Visit
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2. What is important to keep in mind when discussing opioid wean?
Feeling the Wean (2)
C.L.I.P.S.
Who are the highest risk patients?
Opioids & Benzos – killed >16,000 in 2013 (last year data was available) via unintentional overdose
Potentially not safe to prescribe both at the same time (“Do No Harm”)
I allow patient to choose one or the other (Which is helping you more?)
Benzodiazepine Taper:
Withdrawal from BZD can precipitate seizures (unlike opioids)
Can be stopped if taking irregularly
Taper at 10% per month, monthly visits
Will need to increase ancillary services – SSRI/SNRI, BH, counseling, stress reduction, CBT/Trauma care
Hydroxyzine if they need to “take something”
How do I start opioid taper?
Concern for health and unintentional overdose
Pain medicine consult?
Safe to decrease 10-25% per week, but slower wean better tolerated
Framing - “Many say 25% per month, but I find 10% safer and easier”
Split pills (Norco 10mg) or switch to lower dose (MS Contin 15mg x 2 pills instead of 30mg one pill - preferred)
Treat withdrawal symptoms – Antidepressants for existential pain, NSAIDs, Anti-epileptics for neuropathic pain, hydroxyzine for insomnia, clonidine for WD symptoms (rhinorrhea, diarrhea, sweating, tachycardia, hypertension), anti-diarrheal agents
Special thanks to Andrea Rubenstein (KPSR) & Oregon Pain Guidance
What is important to keep in mind when discussing opioid wean?
Patient safety – keep bringing it back to how much we care for and want the patient to be safe