…without a proper assessment and comprehensive civil discussion with your prescriber, it could be very uncomfortable. I recognize that when you’re the one in pain and threatened to have your opioid life-line swiped from your hands or dose drastically reduced, it is a difficult task. But, as the saying goes, “you get more bees with honey than vinegar”.
There are thousands of comments collectively on various paindr.com blogs here, many of which you can find by searching this blog site with key term “withdrawal”, from patients that have had their opioid doses drastically reduced quickly or just plain stopped. The heart wrenching stories are difficult to read and understandably filled with bewilderment and anger.
Without a doubt, there are many patients with chronic pain syndromes that require opioids in order to have a restful sleep or improve function, even if that functionality is minimal. When I am asked by a referring clinician to help with an opioid taper, my response starts with a number of questions.
- What is the reason for the taper (noncompliance, change in medical condition, previously existing medical risk that was missed, fear of regulatory agency, new insurance/institutional/pharmacy policy, etc.?
- How long has the patient been on opioids?
- Is the patient on extended release/long acting opioids or short-acting?
- What is the half-life of their current opioid (how long will it stay in the body after stopped)?
- Is there a better option for this patient other than opioids, or are opioids actually the best option when weighing benefits against risk?
- Is it even appropriate to consider an opioid taper, or is the risk of stopping them worse than the presumed risk of continuing them?
If stopping opioids is appropriate, how should this be done?
- If it’s clear that the patient has not been using their medication, abruptly discontinuing the prescription is generally appropriate.
- If the patient is on a large dose of opioids, they should not be abruptly stopped or significantly reduced without a careful strategic taper unless there are extenuating circumstances.
- If a patient is using opioids for recreational purposes, abruptly stopping the opioid may be an option, but other options include admission to a rehab facility or medication assisted treatment with methadone or buprenorphine.
Abruptly stopping opioids without support increases risk of suicidality in legitimate opioid patients and in persons using opioids recreationally.
Therefore, after all the above are carefully weighed, if opioids must be stopped abruptly, it is reasonable to offer the patient compassionate support that may require counseling or at the very least an open line of communication. Moreover, non-opioid medication support to mitigate opioid withdrawal symptoms are certainly in order.
In fact, almost three years ago to the day, our group published Opioid Withdrawal: A New Look at Medication Options. Practical Pain Management which outlines certain medications that have either been used to blunt withdrawal symptoms, or could help to explain why some patients have a more difficult time than others when abruptly stopping opioids. Since 2015, things have changed. More patients are being forced off of opioids, sometimes for the right reasons, but more often than not these days, for the wrong reasons. Last July Pharmacy Today published Short-term nonopioid agent lessens severity of opioid withdrawal symptoms. They start out by saying “Lofexidine (Lucemyra—US WorldMeds) is the first nonopioid treatment to be FDA approved specifically to mitigate withdrawal symptoms that can occur after abrupt discontinuation of opioids. These withdrawal symptoms—aches and pains, muscle spasms and twitching, stomach cramps, muscular tension, pounding heart, insomnia, feelings of coldness, runny eyes, yawning, and feeling sick—can afflict patients with opioid use disorder (OUD) as well as those who have been using opioids appropriately as prescribed.”
Availability of lofexidine is especially important because for the first time ever, there is specific direction for medical providers on how to dose an FDA approved drug that is indicated for prevention of withdrawal symptoms.
The bottom line here is that aside from the reasons a prescribed opioid is being cut-off by a medical provider, or in the case of a person addicted to opioids for recreational purposes, stopping them abruptly is miserable. And if there is an underlying cardiac and/or stroke risk, the elevated heart rate and blood pressure could be dangerous.
While I’m not advocating that the world come off of opioids (or remain on them), I am suggesting that if you’re one of the persons who is required to stop opioids (right or wrong), please have a civil conversation with your medical provider or your pharmacist to discuss available options that could serve to reduce the angst and misery you might otherwise suffer. And while you’re standing in the office puzzled and angry, take a deep breath and remember that it is YOU who will be leaving the office without opioids; your behavior and candid discussions may influence your comfort over the next several days or weeks. In short, there are options if you provide honey to your buzzing prescriber instead of vinegar.
Always, comments are welcome.