To underscore the case for shifting to a patient-centered approach35 we present sample cases in “How a patient-centered approach to tapering opioids looks in practice.”
SIDEBAR
How a patient-centered approach to tapering opioids looks in practice
Five hypothetical cases illustrate what might happen when a practice shifts from an addiction-centered, dosage-centered approach to one that places the individual at the center of care.
CASE #1: Brett F
Mr. F appears to use medication responsibly; benefits functionally from an opioid; has tolerable adverse effects; does not have significant psychosocial risk factors (based on the score of the Opioid Risk Tool [ORT] or the Screener and Opioid Assessment for Patients with Pain–Revised [SOAPP-R]); and is engaged in effective self-management. Most of Mr. F’s pain is thought to have a nociceptive or neuropathic source.
Mr F could reasonably contemplate continuing current opioid treatment.
Action: If the daily morphine milligram equivalent (MME) dosage is high, Mr. F should be referred to a pain medicine specialist. We recommend a periodic (at least annually) empiric trial of dosage reduction to see whether he is indeed best served by the current dosage.
CASE #2: Brett F (version 2.0)
Envision Mr. F having the same profile in all respects except that he is not engaged in effective self-management.
Optimal treatment of chronic pain often requires supplemental modalities beyond opioids.
Action: Physical therapy; an individualized, ongoing exercise regimen; interventional procedures; weight loss (if the patient is obese); smoking cessation; and improving coping skills for anxiety and depression without pharmacotherapy might not only temporarily alleviate the pain but, over time, improve Mr. F’s physical condition.
If Mr. F is not willing to do more than take the prescribed opioids, nothing is likely to change: Over time, his condition is likely to deteriorate. A patient like Mr. F can be harmed if opioids continue to be prescribed for him long-term.
Further action: If Mr. F won’t engage in broadening the approach to treating his pain, the opioid medication should be tapered, in his long-term best interest. A carrot-and-stick approach can facilitate Mr. F’s involvement in his care.
CASE #3: Clark S
Mr. S has a significant psychosocial component driving his pain: depression.a
Prescribing opioids without addressing the root cause of trauma is not in the patient’s best interest.
Action: Because of Mr. S’s depression, refer him to a behavioral health provider. If you determine that he is emotionally stable, wait until he is engaged in trauma treatment to begin the taper. If he appears unstable (eg, crying in the office, recent psychological stressors, recent impulsive behaviors, poor insight) consider (1) urgent behavioral health referral and (2) prescribing only enough opioid medication (ie, at close intervals) to prevent withdrawal and panic. Consider whether a psychotropic medication might be of benefit (eg, a serotonin–norepinephrine reuptake inhibitor or selective serotonin reuptake inhibitor).
Further action: Harm-reduction steps, such as close monitoring and, perhaps, a change to a buprenorphine product, is indicated, especially when the patient is overwhelmed by recent psychosocial stressors. Harm-reduction treatment is available through Medication-Assisted Therapy (MAT) programs; however, patients often run into difficulty obtaining access to these programs because regulations and laws restrict MAT to patients who have a diagnosis of opioid use disorder (OUD) and because some health plans and pharmacy benefit managers require prior authorization.
CASE #4: Gloria B
Ms. B isn’t managing her medications responsibly—although you don’t suspect OUD.
When a patient has shown the inability to manage opioid medication responsibly, you should delve into the reason to determine your next step.
Action: Evaluate Ms. B for a cognitive disorder or a thought disorder. Alternatively, as in the case of Mr. S, a psychosocial component might underlie her pain; in that case, the same recommendations can be made for her. In addition, you can propose that she identify a responsible person to dispense her medication.
CASE #5: Nicole L
You suspect that Ms. L, who is taking opioid medication to alleviate pain, also has a substance use disorder.
Action: Implement harm-reduction early for Ms. L: Obtain addiction medicine consultation and implement behavioral health strategies for addiction treatment.
A key characteristic of a substance use disorder is loss of control over use of the substance. A patient like Ms. L—who is in pain and who has an active OUD—cannot be expected to manage her opioid use responsibly.
Further action: We recommend that Ms. L be referred to an addiction specialist for MAT. Evidence of the harmreduction benefit of MAT is sufficient to strongly recommend it. Continue any other treatment modalities for pain that Ms. L has been using, such as non-opioid medication, physical therapy, alternative treatments, and behavioral therapy, or begin such treatments as appropriate.
a Depression is not the only psychosocial component that can underlie pain. Others include anxiety, posttraumatic stress disorder, and grief.
An eye toward the future. To inform future approaches to opioid tapering, more resources need to be deployed to
- support screening and risk stratification for PTSD, anxiety, and related disorders at the primary care level,
- continue the effort to identify and treat OUD,
- develop best-practice responses to screening, and
- make harm-reduction strategies that are now reserved for patients with OUD available to those who don't have OUD.
We urge that research be pursued into best practices for chronic pain interventions that target psychological trauma, anxiety, and depression.
CORRESPONDENCE
Bennet Davis MD, 2092 East Calle de Dulcinea, Tucson, AZ 85718; bdavis@ipcaz.org.