Considering a Taper for a Patient Receiving Opioid Therapy

Sarah, a 53-year-old woman, was diagnosed with rheumatoid arthritis (RA) 7 years ago and has tried various disease-modifying antirheumatic drugs (DMARDs) and biologic therapies to manage her pain, without success. Dr Bennett, her rheumatologist, prescribed a daily 40 mg extended-release hydrocodone regimen to alleviate her chronic joint pain and stiffness.
Opioid therapy has taken a toll on Sarah’s health. Sarah has experienced side effects such as nausea, drowsiness, constipation, reduced energy, increasing joint pain, and stiffness. She now requires increasingly higher doses (50-60 morphine milligram equivalents [MMEs]/d) to achieve the same level of pain relief. These adverse effects and need for higher doses led her to consult with Dr Bennett to express her worries about dependency and the long-term effects of opioids. 
Dr Bennett reviews Sarah’s medical history, including her journey with RA, previous treatments, and an assessment of the benefits and risks associated with her opioid therapy. Recognizing the need for change, Dr Bennett considers tapering Sarah’s opioid. 
Dr Bennett and Sarah should evaluate the benefits and risks of opioid therapy in the context of Sarah’s experience. This approach aligns with the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022 CDC Clinical Practice Guideline), which emphasizes that the benefits and risks of opioid therapy change over time and should be evaluated periodically as key factors in determining whether and when to taper. 
If the benefits outweigh the risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. 
If the benefits do not outweigh the risks, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or discontinuation, based on the individual clinical circumstances of the patient.
In Sarah’s case, the absence of evidence of benefit from the higher opioid dosage raises concerns. According to the 2022 CDC Clinical Practice Guideline, opioid therapy should be limited to circumstances where benefits of therapy outweigh risks. For some patients, even at low doses of opioid therapy, benefits may not outweigh the risks. The lack of apparent benefits of opioid therapy in Sarah’s case, in addition to her experience of significant side effects, suggests the need to reevaluate the treatment plan and discuss the possibility of tapering opioids. 
Dr Bennett should aim to avoid or minimize opioid withdrawal during tapering. Opioid withdrawal symptoms can be challenging and uncomfortable and can signal the need to further slow the taper rate. According to the 2022 CDC Clinical Practice Guideline, when reducing or discontinuing opioids, it’s recommended to use a slow taper to minimize symptoms and signs of opioid withdrawal such as anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, or piloerection. 
The 2022 CDC Clinical Practice Guideline, in addition to providing direction on managing opioid withdrawal, outlines other considerations when tapering, including but not limited to the tapering rate, pain management, and behavioral health support. 
The patient’s agreement and interest in the tapering process are important components of a successful outcome. According to the 2022 CDC Clinical Practice Guideline, whenever possible, clinicians should collaborate with the patient on a tapering plan. Tapering is more likely to be successful when patients collaborate in the taper. Tapering should be tailored to the patient’s specific needs and goals and not be rigidly tied to a fixed schedule.
If the patient is not cognitively equipped to make an informed decision, such as in cases of dementia, it is important to involve caregivers in the decision-making process to ensure that the tapering plan is tailored to the patient’s specific circumstances. 
Some patients with unanticipated challenges to tapering, such as inability to make progress in tapering despite opioid-related harm, might have an undiagnosed opioid use disorder (OUD). If there is a concern that OUD may be present, clinicians should: 
Assess for OUD using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria
Offer evidence-based medication treatment and naloxone for opioid overdose reversal
Management of opioid withdrawal symptoms
Pain management
Behavioral health support
Increased risk for overdose
 
Public Information from the CDC and Medscape