The Complexities of Tapering Polypharmacy Regimens

This week I want to share two articles about the complexities of tapering polypharmacy regimens that include opioids. The first article is about using a mix of alternative methods to help treat chronic pain while also reducing the use of opioids. The second article examines the myths surrounding tapering opioid therapy and tips on how to do it successfully. Below you’ll find these articles and my thoughts on their implications.

Disclaimer: The views and opinions expressed below are those of Mark Pew, Senior Vice President of Product Development and Marketing, and do not necessarily reflect the views of Preferred Medical.

Novel Program Improves Chronic Pain, Stops Opioid Use — Medscape subscription required

A study group of 53 people with chronic pain participated in a program that included a comprehensive approach to treatment. This program included physical therapy, psychology, nutrition and other treatments to help the patients reduce their pain. The results showed significant reductions in pain intensity and psychological distress while discontinuing use of opioid pain medications by the end of the 7-week program.

Mark’s Thoughts:
Very positive outcomes for these 53 patients. However, I’m not sure that “novel” is the right term for this method of treating chronic pain. Many interdisciplinary functional restoration programs (FRP) across the country utilize similar whole-person tactics and “focus on function.” I’ve visited many of them in-person since 2011. They’ve all had great success when the patient is ready for change. “In our interdisciplinary model, patients not only work with strength training and physical therapy, but also psychology, nutrition and other modalities to help them get more ownership of their pain and increase their understanding of pain. We thought this would help reduce the central pain, and this is what our study shows.” Great description—the very definition of BioPsychoSocialSpiritual. But this approach is not new (hence my disagreement with the term “novel” to describe it, which was probably coined by the article’s author and not the research clinicians). I’ve been a proponent of the FRP model for several years. If you’re not, get to know it. Two great comments were posted that helps further underscore the point that FRP’s can be very useful but are definitely not “new”:

Thomas Heitkemper Ph.D.Mark, I helped run interdisciplinary pain management programs (a step above “multidisciplinary” programs…the difference is that interdisciplinary programs coordinate and communicate among all treatment components) from 1986 through 1996…We called it the “full court press” approach with simultaneous physical, psychological, social, and vocational reactivation. So indeed, everything old is new again. And we had great outcomes (reduced med use, lower health care utilization and continued vocational goal attainment) at 2-month, 6-month and 1-year follow-up. Many of my psych sessions were done during PT and OT sessions to make sure we were addressing the “hurt versus harm” issue that can lead to pain-avoidant behavior and overall activity intolerance. Our program director, Dr. Peter Vicente (past president of the American Pain Society and one of the most brilliant and passionate persons I’ve ever met) helped develop this model in the early ’80s. Unfortunately, these programs nearly became extinct in part due to the proliferation of modality-specific pain centers and, of course, the siren call of opiates as an answer to dealing with chronic pain.

Geralyn Datz Ph.D.100% on point Mark. These programs are not at all new but were very popular about 3 to 4 decades ago when the healthcare landscape was much different than now. Thankfully there is wisdom in history and indeed, as printed out above, what’s old is new and there is renewed interest in these programs which address both the mind and body and promote self-empowerment and physical movement and strength despite pain. We have seen similar amazing results and also presented our findings at this meeting! So glad to see this getting publicity. More people need to know about these programs.

Opioid Tapering Tips 1: Reducing Opioids without Withdrawal

Joseph Pergolizza Jr, MD, Director of Research, NEMA Research, Inc, has found that long-term opioid therapy may need to be discontinued for reasons such as resolution of the painful condition, intolerable side effects, and development of opioid use disorder. The article also examines several myths that Pergolizza and his colleagues have found about opioid tapering that continue to affect doctors and their patients.

Mark’s Thoughts:
“Among the studies countering this notion (that patients who have been on long-term opioids will not want them discontinued regardless of the resolution or improvement of a painful condition or the possibility of alternative therapies) was one that found 75% of 110 patients in a clinic with chronic non-cancer pain on long-term opioid treatment agreed to taper their dosage, if they could receive help from the clinic to do so. ‘This suggests that patients may be hopeful to decrease or discontinue opioid therapy, providing there is a validated plan in place and they have extensive support as they moved forward,’ Joseph Pergolizzi Jr, MD observed.” Another important quote: “Patients often require supportive care in this vulnerable time and may need help with pain control, tactics to manage withdrawal symptoms, and psychological or emotional comfort.” Read page 2 for his tips on tapering. Obviously they only address opioids. Those typically aren’t the only medications part of the regimen due to the cascading side effects and many of those other drugs also require careful tapering. In a word, tapering is complex. To address that it needs to be an individualized, strategic process. Here are the tips (but I suggest you read the full article anyway):

  1. “The daily dose of opioids needed to prevent acute withdrawal symptoms is approximately 25% of the previous day’s dose. MP NOTE: The 2016 CDC opioid guidelines recommend “A decrease of 10% of the original dose per week is a reasonable starting point. Some patients who have taken opioids for a long time might find even slower tapers (e.g. 10% per month) easier.” The takeaway is that tapering needs to be methodical, strategic and individualized.
  2. If a patient is receiving opioids through different routes of administration, such as transdermal and oral, it may be advisable to convert to a single, extended-release oral product before tapering.
  3. If different opioid products are being used, conversion to a single product should be at roughly the equivalent dose over 24 hours, often expressed in morphine milligram equivalents (MME).
  4. The highest daily morphine equivalent dose (MED) recommended by the CDC is 90mg. Although many patients take higher doses due to tolerance, it is noted that both high dose and extended duration of use are risk factors for OUD.
  5. Short-acting opioids may be helpful at both the initiation and end of tapering the extended-release product, to avoid withdrawal.”

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Until next week,