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Perspectives: Opioid tapering attracting more attention

Reema Hammoud

Opioids have become part of the national conversation and have had their place in workers compensation treatment for more than 20 years, with recent years devoted to better control and weaning for substances now considered too dangerous for haphazard prescribing. 

It is hard to imagine that such widespread devastation — with the U.S. Centers for Disease Control and Prevention reporting nearly 500,000 overdose deaths from 1999 to 2019 — could arise from opioids, a category of drugs originally intended to address moderate to severe pain but which have grown to include synthetic versions that make up most headlines. 

Looking at the data more closely reveals that legal opioid prescriptions are decreasing slightly due to state policies enacted over the last few years. We know that while opioids have been found to be effective in managing certain types of pain, they are also highly addictive. It is when opioids are misused or abused that they can lead to unintended or unimaginable consequences. 

Because of the inherent risk associated with opioids, it is important for employers to understand that precautions should be taken when opioids are prescribed and to be aware of issues around proper tapering strategies. Because of the severity and magnitude of the opioid crisis and the number of individuals affected, this has become an increasing focus of those with workforce responsibilities. 

Tapering — reducing prescriptions and dosing — has been a recent focus in workers comp. Such tapering plans should be tailored to the individual and should aim to minimize symptoms of opioid withdrawal while managing pain with nonpharmacologic therapies and nonopioid medications.

There are several situations that warrant opioid tapering consideration. First is if the person requests a dosage reduction. This can indicate that the person’s mindset is open to change, and they may be more successful in taking the steps necessary to make it happen. Some people claim that effective pain management depends on mental mindset and coping skills to a large degree.

Other indicators that opioid tapering should be considered are if the person is not showing meaningful improvement in pain and function; the person is taking a strong dosage with little improvement; or if opioids are combined with benzodiazepines or other drugs that make for a dangerous combination given enhanced side effects. 

Signs of a substance use disorder are also concerning. For example, look to see if the person displays early warning signs of an overdose risk. This may include aberrant behavior, inconsistencies in urine screenings, breaking the “pain contract” — an agreement with one’s treating physician —  or using recreational drugs such as cannabis while on opioids.

Once a decision has been made to create and introduce an opioid tapering plan for an individual, it is important to implement intended changes slowly. For example, the CDC suggests a decrease of 10% in dosing per month as a starting point if a person has been on opioids for more than a year. For those who have been on opioids for a matter of weeks or months, that decrease may be 10% per week. Be certain that the person understands the elevated risk and consequences of returning to the previously prescribed dosage.

It is also important to coordinate with specialists and treatment experts as needed. Women who are pregnant or people with comorbidities are considered at higher risk and can benefit from working with specialists. Additionally, individuals with a mental health disorder or a propensity for an opioid use disorder may need assistance from mental health providers. 

Patient engagement is also essential to success, and realistic expectations should be established. While there is evidence to suggest that function will improve and pain will decrease over time, each person’s experience will differ. Thus, pain coaching and encouragement may be needed to continue the process.

As with any plan, it is important to monitor results to ensure desired outcomes are being achieved. At the outset,  the benefits and risks of opioids should be considered. Once the plan is underway, clinical assessments and individual information can help determine the proper course of action and what adjustments are needed. Clinicians should not abruptly taper or suddenly discontinue opioid usage nor should they reverse the taper. Once the lowest dosage is reached, it may be possible to extend the interval between doses. 

While the CDC has been tracking opioid usage and offering general guidance for a number of years, the recent study published in the Journal of the American Medical Association in August underscores the attention that opioid tapering is receiving. The study by researchers at University of California, Davis, made headlines for its new — and somewhat controversial — insights about the efficacy of opioid tapering and its effects on mental health and patient well-being. 

According to the researchers, patients who tapered experienced a 68% increase in overdoses and twice the number of mental health crises compared with patients who stayed on their normal dose of medication. Those risks were even more pronounced among patients whose original doses were higher and who reduced their doses more quickly. While its insights raise interesting considerations, the study raises many questions and shows limitations in how the researchers may have fallen short in their approach. Among the questionable characteristics of the approach are limitations in patient population, consideration of comorbidities, and sample size.

While many questions remain in terms of how best to address the opioid crisis on a broad scale, the ability to help a single individual in tapering their opioid usage based on a plan tailored to their specific needs is a very real possibility. And helping individuals reclaim their lives and the lives of those around them is worth the investment and exploration of alternatives.

Reema Hammoud is assistant vice president of clinical pharmacy at third-party administrator Sedgwick Claims Management Services Inc. She is based in Southfield, Michigan. She can be reached at