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Aug
10

Opioids, tapering, and risks – what you need to know

WorkCompCentral’s Mark Powell penned an excellent piece on just-released research on tapering long-term opioid patients.

One finding demands our attention; researchers found a statistically significant increase in overdoses and mental health crises in the 12 months after tapering was concluded. On average, these adverse events (science talk for bad stuff) happened 6 months after tapering concluded.

From the JAMA article:

In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering. These findings suggest that adverse events associated with tapering may be relatively common and support HHS recommendations for more gradual dose reductions when feasible and careful monitoring for withdrawal, substance use, and psychological distress. (emphasis added)

The study included 114,000 patients who had been on stable, higher doses (50+ morphine equivalents) of opioids over an 11-year period. It came on the heels of two chronic pain studies published earlier this year; one addressed opioid treatment for chronic pain and the other was a meta-analysis of 190 studies focused on non-opioid treatment. I wrote about both here.

Tapering is an opioid management approach involving a steady decrease in opioid dosage over a prescribed time. The decreases in dosage and how fast patients were tapered varied significantly among the patient population; patients who were on higher doses before tapering were at increased risk for adverse events.

There were some limitations in the study including; the population was Medicare Advantage and commercially insured; individual patient tapering may have varied after the initial decrease; and the data didn’t indicate if the prescriber or patient initiated the tapering.

A thoughtful and detailed discussion of tapering is here…in part the paper states:

The authors emphasize that any medical action taken should involve as much patient buy-in as possible and should not be driven by rigid opioid dose cutoff s and misinterpreted guidelines. The authors of this paper also support sustaining patients on their existing medication at its existing level if patients are continuing to benefit from use, are not experiencing significant side effects, and express the desire to remain on their current medication as opposed to pursuing a taper. In such cases, the risks of a taper would outweigh the potential benefits.

Regardless, this is a wake-up call to the industry. Yes, workers’ comp – once the addiction creation industry – has made great progress in reducing inappropriate opioid usage and some progress in helping long-term opioid patients reduce or eliminate opioids.

That said, there are a variety of opioid management approaches, and we should be considering – and open to – any and all.  Medication-assisted therapy involving methadone or buprenorphine, physical therapy, acupuncture, yoga, and talk therapy are among the approaches that have shown promise.

I’ll end quoting myself from a post back in 2019;

we need to make very sure we are doing the right thing for patients. In some instances this will involve telling patients what they don’t want to hear; we need to be prepared to do that and help them thru the process, while understanding that process is very difficult.


8 thoughts on “Opioids, tapering, and risks – what you need to know”

  1. Further proof that patients (and secondarily payors) are best served by not going down the road of overprescribing opioids in the first place.

    1. Jeff – well said – the easiest cure is the disease that doesn’t happen.

      be well – Joe

  2. Thank you for sharing Joe. You have been very consistent with this topic, especially around the need to be flexible (not a WC industry strength) in our approach for those who have been on opioids long-term. Yes, we are doing better, but we have to be willing to try alternative forms of treatment that WC just isn’t used to. There is never a one size fits-all-approach to this sort of thing. Keep up the good work!

    1. Brad – thanks for the comment and compliment – will do my best to keep the focus where it needs to be.

      be well – Joe

  3. Joe, thanks for noting this article. One size does not fit all and there are some injured workers who do better overall with increased function, less pain and remaining at work with the judicious use of an opioid.

    1. Thanks for the comment Steve – Perhaps it is time we did another talk on addressing opioid use in work comp…

      be well – Joe

  4. I also think a big part of the entire process – from prescribing to tapering/weaning must always involve setting real expectations from the very first claimant/practitioner interaction. Claimants should know the expectation is for them to get safe, appropriate medical care with the goal of returning to work if at all possible. Physicians should also be expected to explore any and all available options, not just the magic prescription pad. This includes that when necessary – coming off opiates or reducing the dose will be part of this process. The expectation of endless opiate scripts being written for years is NOT reality and that myth should be put to rest in the first claimant/medical professional visit. As said before in these comments – if we don’t start that snowball rolling down the hill – we don’t then need to figure out how to run down the hill after it to stop it. Opiates should not be the first, nor (sadly in many cases) the last option.

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Joe Paduda is the principal of Health Strategy Associates

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