Keeping Up With Clinical Trends — Weaning Opioids After Injury Has Resolved

Michael Nguyen
PharmD, CPh, Director of Clinical Services

Some positive trends have been emerging in the national battle against the opioid epidemic. Overall, opioid utilization is trending downward as providers are becoming more aware of its diminished utility and progressive risks. Long-term use of opioids causes physiological changes in patients that result in psychological and physical symptoms that manifest when the drugs are withdrawn. These withdrawal symptoms are reportedly unpleasant and one of the main reasons patients and providers alike are hesitant to discontinue chronic opioid therapy. The bottom line is that chronic opioid therapy cannot be discontinued abruptly. In this edition of Keeping Up with Clinical Trends, we will address some frequently asked questions about weaning once opioid therapy is no longer needed because the injury has naturally resolved.

 

When should opioid therapy be discontinued?

In the ideal situation, opioid therapy should be discontinued when tissue healing is complete and pain has resolved. It is also recommended by most guidelines to discontinue opioids when there is no improvement in pain and function. Tissue damage may be a result of injury, trauma or surgery. Discontinuation should also be pursued when there is evidence of non-medical use or diversion. Non-medical use is when a patient is using opioids for a purpose other than pain and diversion is usually evident when a compliance urine drug screen is negative for the prescribed opioid(s). The euphoric side effect of opioids is the main reason patients seek prescriptions after their pain has resolved. This is difficult to detect because of the subjective nature of pain. Our clinical pharmacists at myMatrixx have reviewed thousands of cases through our Drug Regimen Review program where the treating physician cannot find objective evidence of pain, yet the patient continues to complain to seek opioid prescriptions. These patients may have developed substance use disorder (SUD) which can otherwise be referred to as addiction. (The treatment approach and ramifications for weaning off patients with SUD is more complicated and controversial, which we will address in a subsequent article.)

The detection of addiction is complicated due to the phenomenon known as pseudo-addiction. This is where a patient demonstrates addiction behavior because he or she is being prescribed an ineffective (sub-therapeutic) dose or is not responding to the particular opioid being prescribed. Genetic variability can factor in to which drugs a patient may or may not respond.

 

What is the rate at which opioid therapy should be discontinued?

Immediate discontinuation is recommended when there is evidence of diversion or non-medical use. These patients should be tapered rapidly over a 2-3 week period. Patients whose injury has healed and pain has resolved should be tapered gradually. The general recommendation is 10% or less of the current dose per week. The CDC Guideline for Prescribing Opioids for Chronic Pain also recommends tapering slower than 10% per week (e.g., 10% per month) as it may be appropriate and better tolerated. Tapers may also have to be paused and restarted again when the patient is ready to continue tapering. As long as the patient is making progress, tapers may be considered successful. In practice, these guidance statements from the CDC may be difficult to digest when the pause period can last for months. For these reasons, when a treating physician accepts and initiates a weaning recommendation made via our Drug Regimen Review program, our clinical pharmacist team maintains a collaborative relationship with the physician to gather on-going feedback on the weaning process. It is our priority to facilitate progress towards complete discontinuation of opioid therapy.

 

How can withdrawal symptoms be minimized or managed?

Withdrawal (also referred to as opioid abstinence syndrome) can be unpleasant but is rarely serious in generally healthy patients. In patients with serious underlying comorbid health conditions (e.g., cardiovascular disease; mental illness), withdrawal symptoms can precipitate the need for inpatient medically supervised opioid withdrawal. The symptoms themselves and severity can vary from one patient to the next. In generally healthy patients, symptoms such as restlessness, sweating or tremors can be managed with clonidine, which is a cardiovascular drug that has been studied and is shown to decrease the severity and duration of opioid withdrawal. Other symptoms such as nausea can be managed by using antiemetics such as ondansetron, promethazine or prochlorperazine. Diarrhea can be managed with agents such as loperamide or anti-spasmodics, such as dicyclomine. It also important to maintain adequate hydration in patients experiencing diarrhea as dehydration can be a serious complication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for patients experiencing muscle pain and neuroleptics such as gabapentin can be used for patients experiencing neuropathic pain. Myoclonus (muscle twitching) is recommended to be treated with skeletal muscle relaxants such as cyclobenzaprine, tizanidine or methocarbamol. Insomnia is also very common and should be treated with sedating antidepressants such as nortriptyline, mirtazapine or trazodone. Lastly, another very common symptom of opioid abstinence syndrome is anxiety, which a selective serotonin-reuptake-inhibitor-antidepressant (e.g., sertraline; citalopram; paroxetine) is recommended.

 

Summary

It is generally recommended that all opioid treatment regimens incorporate some process for stopping, as the evidence for long-term safety and efficacy is lacking. It is a recommended best practice to incorporate this parameter into the opioid agreement between the patient and treatment physician before opioid therapy is initiated. The addictive nature of these drugs, however, presents many challenges for doing this in practice. The above recommendations are general and are presented with the caveat that opioid weaning should be individualized to a patient’s particular needs and clinical presentation.

The most difficult part of opioid weaning is getting started, especially for patients that have been on therapy for years. At myMatrixx, we take particular pride in our unique method of engaging providers about the need for opioid weaning when medically necessary. We perform a comprehensive review of a patient’s medical history with our Drug Regimen Review program and only make the recommendation to wean a patient when we are confident that it would be in the patient’s best interest to do so.

There is also evidence that the symptoms of opioid abstinence syndrome can persist long after opioid therapy has successfully been discontinued and for that reason palliative pharmacotherapy may be required for an undefined period of time. We are very proud of the many successes we have made in our endeavor to fight the opioid crisis but are cognizant that the fight is far from over. We are actively engaging innovative technologies to identify at risk patients and encourage our passionate claims professional partners to refer to us for your most difficult and complex patients.