This paper looks at the challenges that are the real-world obstacles for patients and providers considering making changes to a patient’s opioid therapy. It’s often not a black-and-white issue because nowhere in state or federal guidelines is there a mandate for patients who have been stable on higher opioid doses to be unilaterally told by the provider that they must taper. That’s a big point of misunderstanding among providers nowadays.

We all know the risks of opioid misuse, but we should avoid getting into a panic about patients who have engaged in stable use of opioids over a longitudinal course of treatment. In those cases, we should be rational and methodical in our approach, and we want to work in concert with our patients. If the decision is made to taper, and the patient runs into difficulty, it might be reasonable for the provider to say at a given point, “Well, let’s pause and delay further tapering, let’s try to get you settled on the current dose. We’d rather not to go back up, but let’s delay further tapering for now, then we’ll check again in a few weeks to see how things are going.” We have to be humane. We can also offer choices, such as “Maybe we should try switching to another opioid that you’re not as tolerant to.” That would involve initiating a relatively lower dose of the new opioid, thereby getting the opioid dose down. With regard to tapering the existing opioid(s), providers should avoid a mentality of pressing forward at all costs, “damn the torpedoes,” regardless of what the patient’s feedback is on their perception of significant negatives to their quality of life that are accompanying the tapering process.

Some of the recommendations that come in the article — such as identifying the social, emotional, and health factors that will impact patients’ tapering; addressing patient fears, including fears of abandonment; and, proposing tapering only when you believe it is in the patient’s best interest — underscore the importance of seeing pain treatment as a team endeavor. Rather than engaging in care that feels punitive or one-sided, or blaming the government’s policies and framing your recommendations in terms of a mandate when in fact there is not a mandate, we should aim for trust and mutual goal-setting with our patients whenever possible.

The work by Henry et al, addresses a complex clinical scenario that has become an important part of medical practice in a patient-centered, comprehensive way. While the design of the study is necessarily subjective and may suffer selection bias as the authors note, patient perspectives related to chronic pain, opioid use and tapering are critical in guiding practice. 

The most important consideration when considering an opioid taper is assessment of the risks and benefits. Previously reported work has focused on the demonstrated risk of higher dose opioid therapy, particularly more than 90 morphine milligram equivalents a day. However, evidence for benefit of long-term higher dose opioid therapy for those with severe, chronic pain is lacking, which is not the same as lack of benefit.  At the same time, the incidence of risks associated with rapid tapering, abandonment and chronic poorly controlled pain including transition to illicit opioids, reduced functionality, depression and suicide is relatively poorly understood. 

Given these competing factors, individual assessment of functionality, tolerance, adverse effects and risks must be considered when contemplating a taper from established, high-dose opioid regimens, particularly for the vast majority of patients who have not demonstrated misuse or addictive behavior. Frequently, tolerance and dependence, which are anticipated, predictable outcomes of long-term opioid therapy, are erroneously conflated with misuse and addiction which leads to real and perceived stigma among patients on chronic opioid therapy. When tapering is performed, anticipation of withdrawal symptoms, both physical and psychological, should be expected, ameliorated and frequently assessed through open, honest and empathic communication between patient and physician. 

The association of markedly increased opioid prescribing with increased opioid misuse and addiction leading to an epidemic of overdose deaths has resulted in attempts to reduce opioid prescribing through interventions including guideline development and provider clinical decision support tool implementation. Ideally, these tools will be implemented as part of a coordinated plan with the focus solely on the health and well-being of each individual patient, recognizing the significant variability in social, physiological and mental health factors that contribute to pain and risk of substance use disorder. Henry and colleagues’ work sought to provide a sample of the diverse nature of patient experiences with pain and pain management with a core message that open and honest communication with patients regarding their health care and provider focus on individual health and well-being rather than arbitrary application of uniform standards and recommendations is paramount. The need to focus on individual patient goals and function is typically recognized in published guidelines, but often overlooked when applied to regulatory standards or predefined norms of practice. Great caution should be taken with translation of guidelines, meant as general guidance for many but not all patients, into legislative, insurer, or practice-based mandates. These concerns were clearly reflected by the patients who participated in Henry et al’s study.

These researchers have collected and summarized patient experiences with opioid therapy and tapering. Minimizing excessive opioid exposure while optimizing nonopioid and nonpharmacologic treatment strategies for pain are appropriate goals. This work highlights the need for communication of risks, benefits, goals, fears, and expectations among health care providers and patients to achieve the best possible combination of function, pain relief, and safety.