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Medically supervised taper for ultra high-dose opioids with significant comorbidities using a multidisciplinary approach: A case report

Denise Wilkes, MD, PhD, Jasmine M. Mitchell, MD, Kip John Winden, DO, David Parker, MD

Abstract


Introduction: The opioid epidemic and current opioid use guidelines for chronic noncancer pain have resulted in an overwhelmingly large number of patients undergoing opioid tapers. Even though the literature for tapering guidelines is growing, there is little guidance for tapering patients on ultra high-dose opioids.

Case description: This case report describes in detail the opioid tapering approach used to taper a 53-year-old male with chronic low back pain on a regimen of a morphine equivalent daily dose (MEDD) of 1,990 mg. Patient reported many side effects such as chronic nausea, irritability, psychomotor depression, and functional impairment. He was admitted for a medically supervised opioid taper for 12 days.

Results: The patient was discharged with an MEDD of 392 mg with additional taper as an outpatient to an MEDD of 200 mg. Adequate pain relief and resolution of side effects were achieved without the patient reporting significant withdrawal symptomatology in the outpatient setting.

 


Keywords


opioid taper, wean, opioids, chronic pain, multidisciplinary approach

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References


Levy N, Sturgess J, Mills P: “Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: Why? Br J Anaesth. 2018; 120: 435-438.

Baker DW: The Joint Commission’s Pain Standards: Origins and Evolution. Oakbrook Terrace, IL: The Joint Commission, 2017.

Ivanova JI, Birnbaum HG, Schiller M, et al.: Real-world practice patterns, health-care utilization, and costs in patients with low back pain: The long road to guideline-concordant care. Spine J. 2011; 11: 622-632.

Morasco BJ, Yarborough BJ, Smith NX, et al.: Higher prescription opioid dose is associated with worse patient-reported pain outcomes and more health care utilization. J Pain. 2017; 18: 437-445.

Fassio V, Aspinall SL, Zhao X, et al.: Trends in opioid and nonsteroidal anti-inflammatory use and adverse events. Am J Manag Care. 2018; 24: E61-E72.

Ballantyne JC, Shin NS: Efficacy of opioids for chronic pain: A review of the evidence. Clin J Pain. 2008; 24: 469-478.

Zhou K, Jia P, Bhargava S, et al.: Opioid tapering in patients with prescription opioid use disorder: A retrospective study. Scand J Pain. 2017; 17: 167-173.

Garcia MC, Dodek AB, Kowalski T, et al.: Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011-2015. MMWR Morb Mortal Wkly Rep. 2016; 65: 1125-1131.

Page J, Traver R, Patel S, et al.: Implementation of a proactive pilot health plan-driven opioid tapering program to decrease chronic opioid use for conditions of the back and spine in a Medicaid population. JMCP. 2018; 24: 191-196.

Darnall BD, Ziadni MS, Stieg RL, et al.: Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Intern Med. 2018; 178: 707-708.

Kroenke K, Alford DP, Argoff C, et al.: Challenges with implementing the centers for disease control and prevention opioid guideline: A consensus panel report. Pain Med. 2019; 20: 724-735.

Rosenberg JM, Bilka BM, Wilson SM, et al.: Opioid therapy for chronic pain: Overview of the 2017 US department of veterans affairs and US department of defense clinical practice guideline. Pain Med. 2018; 19: 928-941.

Antoniou T, Ala-Leppilampi K, Shearer D, et al.: Like being put on an ice floe and shoved away: A qualitative study of the impacts of opioid-related policy changes on people who take opioids. Int J Drug Policy. 2019; 66: 15-22.

Pergolizzi JV, Rosenblatt M, LeQuang JA: Three years down the road: The aftermath of the CDC guideline for prescribing opioids for chronic pain. Adv Ther. 2019; 36: 1235-1240.

Pergolizzi JV Jr, Rosenblatt M, Mariano DJ, et al.: Clinical considerations about opioid withdrawal syndrome. Pain Manage. 2019; 9(2): 111-113.

Eccleston C, Fisher E, Thomas KH, et al.: Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev. 2017; 11: Cd010323.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016CDC guideline for prescribing opioids for chronic pain, 2016CDC guideline for prescribing opioids for chronic pain, 2016. JAMA. 2016; 315: 1624-1645.

Kertesz SG, Manhapra A: The drive to taper opioids: Mind the evidence, and the ethics. Spinal Cord Ser Cases. 2018; 4: 64.

Darnall BD, Juurlink D, Kerns RD, et al.: International stakeholder community of pain experts and leaders call for an urgent action on forced opioid tapering. Pain Med. 2019; 20: 429-433.

Cunningham JL, Evans MM, King SM, et al.: Opioid tapering in fibromyalgia patients: Experience from an interdisciplinary pain rehabilitation program. Pain Med. 2016; 17: 1676-1685.

Wesson DR, Ling W: The clinical opiate withdrawal scale (COWS). J Psychoactive Drugs. 2003; 35: 253-259.

Services WSDoSaH: Tapering plan for client with chronic. Non-Cancer Pain. (ed 7-7-15), 2015.

Deyo RA, Von Korff M, Duhrkoop D: Opioids for low back pain. BMJ. 2015; 350: G6380-G6380.

Chaparro LE, Furlan AD, Deshpande A, et al.: Opioids compared with placebo or other treatments for chronic low back pain: An update of the cochrane review. Spine (Phila Pa 1976). 2014; 39: 556-563.

Berna C, Kulich RJ, Rathmell JP: Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice. Mayo Clin Proc. 2015; 90: 828-842.

Sullivan MD, Turner JA, DiLodovico C, et al.: Prescription opioid taper support for outpatients with chronic pain: A randomized controlled trial. J Pain. 2017; 18: 308-318.

Pergolizzi JV, Varrassi G, Paladini A, et al.: Stopping or decreasing opioid therapy in patients on chronic opioid therapy. Pain Ther. 2019; 8: 163-176.

Sullivan DS, Boudreau D, Ichikawa L, et al.: Primary care opioid taper plans are associated with sustained opioid dose reduction. J Gen Intern Med. 2020; 35: 687-695.

Baron MJ, McDonald PW: Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. J Opioid Manag. 2006; 2: 277-282.

Darchuk KM, Townsend CO, Rome JD, et al.: Longitudinal treatment outcomes for geriatric patients with chronic noncancer pain at an interdisciplinary pain rehabilitation program. Pain Med. 2010; 11: 1352-1364.

Affairs DoV: Tapering and Discontinuing Opioids. Washington, DC: Dept of Veterans Affairs, 2013.

Nielsen S, Larance B, Lintzeris N: Opioid agonist treatment for patients with dependence on prescription opioids. JAMA. 2017; 317: 967-968.

Fitzgibbon DR, Rathmell JP, Michna E, et al.: Malpractice claims associated with medication management for chronic pain. Anesthesiology. 2010; 112: 948-956.

Prevention CfDCa: Suicide Rates Rising Across the US. Atlanta, Centers for Disease Control and Prevention, 2018.

Perez HR, Buonora M, Cunningham CO, et al.: Opioid taper is associated with subsequent termination of care: A retrospective cohort study. J Gen Intern Med. 2020; 35: 36-42.

Black RA, McCaffrey SA, Villapiano AJ, et al.: Development and validation of an eight-item brief form of the SOAPP-R (SOAPP-8). Pain Med. 2018; 19: 1982-1987.

Kaye AD, Jones MR, Kaye AM, et al.: Prescription opioid abuse in chronic pain: An updated review of opioid abuse predictors and strategies to curb opioid abuse: Part 1. Pain Phys. 2017; 2: S93-S109.

Cheatle MD, Compton PA, Dhingra L, et al.: Development of the revised opioid risk tool to predict opioid use disorder in patients with chronic nonmalignant pain. J Pain. 2019; 20: 842-851.




DOI: https://doi.org/10.5055/jom.2022.0698

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