Department of Health and Human Services Issues New Opioid Guidelines
This past July, CMS issued an educational piece that warned of the dangers associated with the concurrent use of opioids and benzodiazepines. You may have seen our blog on the CMS publication. If you missed that blog, you can read it here. In October, the Department of Health and Human Services (HHS) issued guidelines on the dosage reduction and discontinuation of opioid drugs. This latest publication is another example of the governmental effort being put forth to curb the opioid crisis in the United States. Through these efforts to change prescribing patterns and reserve opioid therapy for situations that truly warrant these drugs, opioids will be less accessible to those who may misuse them.
In the introductory paragraph of the publication, HHS promotes the thoughtful, conservative use of opioids as being beneficial for both individual patients as well as the public at large. Following this overarching message, HHS unambiguously states that treatment decisions must be based on an individualized assessment of benefits and risks, including the patient’s diagnosis, circumstances and unique needs. The remainder of the article is devoted to more specific considerations for the tapering and discontinuation of opioids that were taken from other credible sources including the Centers for Disease Control guidelines, Veterans Administration/Department of Defense guidelines and various peer-reviewed literature sources. In this blog, we’ll highlight some of the points discussed in the HHS opioid tapering guidelines. This blog should not be treated as a substitute for a full review of the guidelines or for the judgement of any health care professional.
Tapering of opioid medications should be considered in a variety of circumstances, including situations where the patient’s pain level has improved, the patient has evidenced opioid misuse or the patient is taking other medications (such as benzodiazepines) that increase the risk of adverse events. There are a few things that are recommended to take place prior to initiating a taper. For example, it is important for the prescriber to collaborate with the patient on the tapering plan and to obtain patient buy-in. Integrating nonpharmacologic treatments and/or nonopioid drug therapy before or during the taper can help to avoid an increase in pain during the process of tapering.
The rate of tapering must be individualized to the patient but generally speaking, a taper involves a 5% to 20% dose reduction every 4 weeks. A slower taper may be needed for a patient who has been taking opioids for an extended period of time. A faster taper may be appropriate if there are patient safety concerns associated with continuing opioid therapy. If the taper does not proceed as expected, the prescriber should consider pausing the taper and restarting when the patient feels ready. After the smallest effective opioid dose has been reached, a taper can be continued by maintaining that dose and extending the interval between doses. Although one of the goals of the taper should be to avoid symptoms of opioid withdrawal, it may nonetheless occur and should be managed appropriately. Other medications may be needed on a short-term basis to manage symptoms of withdrawal. In cases where patients are unable or unwilling to taper opioid medications, the prescriber should assess the patient for opioid use disorder and consider converting the patient to another drug called buprenorphine. In patients who have been converted to buprenorphine, the buprenorphine is continued or tapered in the prescriber’s discretion.
These guidelines offer treating providers a comprehensive, clinically relevant tool that can be used to optimize patient therapy and effectively preserve opioid medications for situations where the benefits outweigh the risk. You can read the full guidelines here. Over the past year or so, we’ve detailed many of the government’s efforts to combat the opioid epidemic. This is the most recent example of governmental support for a critically important problem that poses a significant risk to public health and safety. We’ll continue to monitor efforts to curb the opioid crisis and post updates here.