Stigma and safety fears have made daily dose tapering of opioid prescriptions more common. New research shows tapering can occur at rates as much as six times higher than recommended, putting patients at risk of withdrawal, uncontrolled pain or mental health crises.
UC Davis physicians advise caution, collaboration with patients on tapering plans.
Stigma and safety fears have made daily dose tapering of opioid prescriptions more common. New research from UC Davis Health physicians, however, shows tapering can occur at rates as much as six times higher than recommended, putting patients at risk of withdrawal, uncontrolled pain or mental health crises.
The study ― “Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017” ― published on November 15, 2019, in JAMA Network Open. The results also will be presented at the November 16-19 North American Primary Care Research Group meeting in Toronto.
“Tapering plans should be based on the needs and histories of each patient and adjusted as needed to avoid adverse outcomes.”
“Tapering plans should be based on the needs and histories of each patient and adjusted as needed to avoid adverse outcomes,” said study author Alicia Agnoli, assistant professor of family and community medicine. “Unfortunately, a lot of tapering occurs due to policy pressures and a rush to get doses below a specific and sometimes arbitrary threshold. That approach can be detrimental in the long run.”
In 2016, the U.S. Centers for Disease Control and Prevention (CDC) recommended dose tapering, or a slow reduction in prescription opioid doses, if the risks of continuing opioids outweigh the benefits. That point in time is usually when a patient is taking 90 morphine milligram equivalents ― or MMEs ― each day, and that dose is no longer reducing pain or improving daily functions. The CDC advises a slow decrease of 10% MMEs per month.
The study team set out to examine trends in opioid dose tapering and if tapering rates were consistent with CDC recommendations.
“We wanted to understand how often opioid dose tapering happens, how rapidly patients’ doses were being reduced when tapering, and which patients were more likely to have doses tapered,” said lead author Joshua Fenton, professor of family and community medicine.
Tapering faster than recommended
Fenton and Agnoli evaluated medical and pharmacy claims and enrollment records for more than 100,000 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities, and locations across the U.S. They focused on individuals whose opioid doses were stable for at least a year and identified tapering patients as those with a 15% or more reduction in daily MMEs during a seven-month follow-up period.
They found that the rate of dose reduction often was well beyond the CDC’s recommendation of 10% per month.
They found that dose tapering became more common throughout the study period of 2008-2017, with the biggest jump following the CDC’s 2016 prescribing guidelines. Tapering increased from 10.5% to 13.7% from 2008 to 2015, and from 16.2% to 22.4% from 2016 to 2017. Tapering was much more common in patients prescribed higher opioid dosages.
They also found that the rate of dose reduction often was well beyond the CDC’s recommendation of 10% per month. The average reduction overall was 27.6% per month. Nearly 20% of patients tapered at a rate of 40% per month, and 5% tapered at a rate faster than 60% per month.
The 2016 policy could have been misinterpreted, leading many prescribers and health systems to insist on faster-than-recommended tapering, according to Agnoli.
“There is definitely a lot of pressure to reduce opioid use among patients, but there also is a need for more training and guidance for prescribers on how to help them safely do so,” Agnoli said.
Women and tapering
Fenton and Agnoli also identified patient variables associated with tapering and uncovered an interesting difference in tapering rates based on sex.
While men have much higher rates of opioid use disorder and adverse outcomes related to opioids, women were more likely than men to have their opioid doses tapered.
While men have much higher rates of opioid use disorder and adverse outcomes related to opioids, women were more likely than men to have their opioid doses tapered.
“We think this has a lot to do with the gender dynamics of pain management and the physician-patient relationship,” Agnoli said. “How women experience pain and discuss pain with their physicians is perhaps very different than men. There also could be some sex bias in terms of the patients that physicians choose to initiate conversations with about dose reduction.”
Minimizing tapering risks
The researchers hope to build on this work to inform best practices for safe decision-making around dose reduction for all patients prescribed opioids.
“Ultimately, we want to clarify the effects of tapering on patients and how to help them taper to maximize benefits and minimize risks,” Fenton said. “We expect this line of research will have important implications for how physicians manage and monitor patients who are undergoing opioid tapering.”
Collaborators on this research were Guibo Xing, Daniel Tancredi, Anthony Jerant, and Elizabeth Magnan of UC Davis Health, and Lillian Hang and Aylin Altan of OptumLabs in Minneapolis.
Their study was supported by UC Davis Health and OptumLabs and is available online.
Reference: “Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017” by Joshua J. Fenton, MD, MPH; Alicia L. Agnoli, MD, MPH, MHS; Guibo Xing, PhD; Lillian Hang, MBA, MPH; Aylin E. Altan, PhD; Daniel J. Tancredi, PhD; Anthony Jerant, MD; Elizabeth Magnan, MD, PhD, 15 November 2019, Pharmacy and Clinical Pharmacology.
DOI: 10.1001/jamanetworkopen.2019.16271
Thank you for your insightful article on the faster than recommended tapering of opioids in the clinical setting.
I was one of those patients, and have been paying the price for it when my own Dr. really began to feel the pressure being exerted on him and his colleagues following the CDC’s 2016 announcement.
I almost feel as if I was one of the “lucky ones” in his practice, because the really HARD push to get me to “conform” didn’t arrive until 2018, almost two years after the CDC announcement. That was only because, as he often told me, that I was his ONLY patient with Complex Regional Pain Syndrome 1 (CRPS1), aka Reflex Sympathetic Dystrophy (RSD), very often described in Medical Journals as the MOST painful condition known to mankind. My opioid medication, even at the relative “high” doses (90MME+) barely scratched the surface of relief, and I am this minute, just like I am most minutes of every day, lying in bed with my heating pad, my right hip, buttock, and leg covered in a patchwork of Lidoderm patches, seeking, and dreaming, of a day, a moment, that now, after 10+ years, I know will NEVER COME.
My tapering was quite rapid – at first, 50% of my main opioid and 66% of my breakthrough pain opioid immediately and then 3 months later, I was taken off all of those, and was given 2mg buphrenorphine (still an opioid) 3 times daily, which I continue now, 6 months later. Was it difficult? Yes, and no. The little amount of actual physical pain relief, even the highest doses gave was, in hindsight, more significant than I realized. I have both, an extremely high tolerance, and high threshold to pain, which my Dr. says is quite “remarkable” (his words, not mine), and he says it is quite uncommon to have both. I also did not have any “emotional” connection, craving, or addiction to, or for, opioids, so I’m sure that helped in my titration as well. I can’t feel that the buphrenorphine has much value for me in terms of actual relief of the pain associated with my CRPS1, and I’ll speak with my physician regarding that early next year.
BTW – in reference to the article saying women were titrated down on opioids much more rapidly than men, I have to agree with that!
I’m an “Intractable Pain Syndrome” sufferer, dating back 25 years, after a near-fatal car accident, followed by being electrocuted while standing in water. I’ve been diagnosed with CRPS, (RDS), Spondylosis, nerve pain, severe muscle, joint stiffness, and bone pain, among other pain issues. I’d been successfully treated with opioids for the last 23 years, and had been able to continue enjoying my life, until the time when my GP had tapered my dosage to a barely functional amount. I’ve always complied with all of my Dr’s requests for tests, including regular drug tests, and I’d paid to see 3 separate outside Pain Specialists, all of whom said that my use of opioids was as it should be, and that it didn’t warrant my seeing a Pain Specialist for treatment. I was on the minimal doses possible for my pain illnesses. I’d always complied with my Dr’s every suggestion or request, without ever any impropriety on my part.
Then, about 6 months ago, when without reason or explanation, my Dr. abruptly discontinued my opioid pain medication.
Since that time, my once pretty functional life and abilities that allowed me a semblance of a normal life have abruptly ceased. I’ve gone from having the ability to care from my horses, cattle, and dogs, (as I’d been a cattle rancher), let alone my family, and myself. My muscle mass has dwindled significantly, and I’ve lost almost 40 lbs., over a year’s time, starting with my last major taper, through my forced discontinuation of all narcotic pain meds.
I’m no longer able to get out of bed for more than a very minimal time, (15 minutes maximum, on a “good day”). I can no longer drive, let alone prepare a meal for myself, and so much more.
I’m now bed bound, suffering from severe intractable pain, weakness, and severe muscle, joint, and bone pain, chronic neck and back pain, and nightly headaches, along with other chronic pain issues.
I feel as if I no longer have a viable quality of life, but there seems to be no alternatives for me. It appears that chronic pain sufferers have become “expendable”, in the ‘war on drugs’, which seems to have now shifted to severe pain sufferers.