Undoing the harm: Tapering down from high-dose opioids

For many years, health care providers like me were told that we were undertreating pain and that pain was a vital sign that needed to be measured. Concurrently, we were reassured that opioids were a safe and effective way to treat pain, with very little potential for development of abuse. As a result, opioid prescriptions in the United States skyrocketed. A common way to compare opioids is to calculate their strength relative to morphine, called morphine milligram equivalents, or MMEs. In 1992, our country dispensed 25 billion MMEs of prescription opioids; by 2011, that number had reached 242 billion. Meanwhile, opioid-related deaths and treatment admissions increased in parallel.

Over the past several years, we have come to recognize that high doses of opioids for patients with chronic, non-cancer pain can be extremely dangerous. Furthermore, there is increasing evidence that long-term opioid therapy is not very efficacious. Multiple studies culminated in the Centers for Disease Control and Prevention (CDC)’s 2016 Guideline for Prescribing Opioids for Chronic Pain, which states that providers "should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day." As a point of reference, a commonly prescribed opioid is oxycodone, the medicine in the brand name Percocet. A 5-mg dose of oxycodone equals 7.5 MMEs, so you would reach the 90 MME threshold by taking 12 or more of these pills per day.

The guidelines raised several concerns among patients with chronic pain on high-dose opioids, as well as the providers who cared for them. Should patients on more than 90 MME be abruptly cut off? Should a rapid taper occur to get to the safe upper limit? What should be done if a patient has been on a stable, but high, dose of opioids for a long time and they are doing well? A recent open letter written by a group called Health Professionals for Patients in Pain and signed by hundreds of experts across the country made some scathing accusations: doctors and regulators believed that the 90 MME cutoff was an absolute dose limit, which led providers, pharmacists, and patients to come under suspicion; insurer-imposed barriers, pharmacy limitations, and metrics were then applied that adversely affected patients on high-dose opioids; and some patients had even turned to suicide or illicit substance use as a result of this unnecessary suffering.

The CDC responded promptly and clarified. Dr. Robert Redfield, the director of the CDC, wrote a letter that explains several key items:

• The guideline does not endorse mandated or abrupt dose reduction or discontinuation.
• The guideline recommends tapering only when patient harm outweighs the benefit of opioid therapy.
• The cutoff of 90 MME is actually for patients with new starts on opioids — not chronic opioid use.
• The guideline recommends creating personalized plans for tapering, ensuring that it be slow enough to minimize opioid withdrawal, for example a 10% a week or even 10% a month decrease for those who have been on high-dose opioids for years.

The authors of the CDC guideline also responded with their own similar article in the New England Journal of Medicine.

The FDA also weighed in, stating that opioids should not be abruptly discontinued in patients who have physical dependence. They continue: "When you and your patient have agreed to taper the dose of opioid analgesic, consider a variety of factors, including the dose of the drug, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient. No standard opioid tapering schedule exists that is suitable for all patients. Create a patient-specific plan to gradually taper the dose of the opioid and ensure ongoing monitoring and support, as needed, to avoid serious withdrawal symptoms, worsening of the patient’s pain, or psychological distress."

So where does this leave patients on high-dose opioids? First of all, if this applies to you, be safe. The combination of opioids and benzodiazepines (another class of sedating medications) can be extremely dangerous, and you should avoid taking both. Likewise, your provider should follow safe prescribing practices like seeing you at least every three months to assess if opioids are working for your pain, having you sign a pain treatment agreement, reviewing your prescription drug monitoring program history, prescribing you a naloxone overdose reversal kit, and performing random drug tests. Although some of these steps may feel punitive, they are designed to keep you safe and prevent you from developing an addiction. Additionally, in light of recent evidence demonstrating that opioids provide only limited benefit for chronic non-cancer pain, and given their known dangers, this may be the time to discuss a gradual tapering of opioids on a schedule that both you and your provider are comfortable with.