By Jim Lichauer, PharmD, BCPS, FASHP
At a recent business meeting, I had breakfast with a man and we talked about work. When I explained my work on the opioid crisis, he shared his story of struggling to stop taking opioids following a routine joint replacement surgery. He said he had taken the medication as prescribed, not more frequently, and for legitimate post-operative pain.
After taking the medication for several weeks, he said his body developed a physical dependence to the opioids. He then tried to wean himself off the drug. He had no training on how to do it, nor was he aware of the risks involved, and he soon found himself returning to the pharmacy for a refill. Each time he tried to stop taking the medication, he experienced withdrawal symptoms that would only go away with more opioids.
As we know, this is where his life could have gone horribly wrong. He could have begun soliciting refills until cutoff, “doctor shopping” and then turning to illicit drugs in order to stave off withdrawal. Fortunately, he paused to think about his future and decided against refilling his prescription. His reward for making the right decision was several difficult days of moderate withdrawal, described as flu-like symptoms. This man was brave in his choice and lucky he made it through the withdrawal. Many don’t. Even more important, his experience could have been minimized or prevented.
In my work at Vizient leading our Opioid Stewardship Collaborative, an assembled group of mostly pharmacists and nurses and some physicians from 18 member hospitals, we realized the magnitude of this issue and worked with participants to identify pain management protocols for discharge medications that include tapering strategies for patients.
Patients don’t know how to wean off opioids
Almost 100 million surgical procedures are performed in the United States each year. And although not all of these patients receive an opioid prescription post-operatively, the risk of continued opioid use for those who do is about 6%. Data published by the CDC also shows that use of prescription refills after a patient’s initial opioid prescription is associated with an increased incidence of persistent opioid use at one year.
The Vizient Opioid Stewardship Collaborative specifically addressed discharge medication and prescription quantities in orthopedic populations. We found that patients often seek refills because they are not aware of how to slowly stop their opioid medications in a way that would prevent or reduce withdrawal symptoms.
The lack of knowledge seems simple enough to address, but it reveals a systemic issue. Most patients are not instructed on how to taper their medications because physicians are not trained to provide this instruction. And as an industry, we haven’t viewed the process of stopping opioid prescriptions as an issue. We now know that when some patients stop opioids abruptly after consistent use over several weeks, withdrawal symptoms may follow. And that’s how opioid dependency starts.
Since we know how habit-forming opioids can be, our stewardship must not only be focused on reducing prescription quantities. It must also help patients understand the dangers of the drug and teach them how to stop using them safely — and with as few withdrawal symptoms as possible.
Train physicians how to wean patients off opioids
From the provider perspective, appropriate patient selection has been a major focus in addressing the opioid crisis. However, proper stewardship should also include patient education on appropriate discontinuation strategies.
The U.S. Department of Health and Human Services (HHS) recently released its Guide to Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesic. The document focuses on reduction of long-term opioid use and includes information on the risks of tapering, steps to take prior to tapering and information relevant to patients who have developed physical dependence from short courses of therapy. The guide should be used when evaluating risks and benefits of continuing opioid therapy and for developing a treatment plan when deciding to taper opioids.
Additionally, here are five key takeaways from our Collaborative to consider in your opioid stewardship practices to help your patients minimize opioid-related risks and appropriately discontinue opioids:
- Consider opioid alternatives: Use multi-modal and non-opioid therapy, such as nonsteroidal agents or nonpharmacological methods, post-operative and at discharge in order to avoid or minimize the exposure to opioids.
- Assess patient history: Prior to surgery, assess the need for discharge opioids and post-operative pain medications based on the patient’s history. Do not pre-prescribe or prescribe opioids as a routine, and only prescribe opioids at discharge if necessary.
- Use minimal dosing: Prescribe the lowest dose and quantity necessary and do not routinely provide refills. Here are a few good resources to guide procedure-specific discharge prescription quantities.
- Michigan OPEN (Opioid Prescribing Engagement Network)
- Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus
- OTA Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury
- Educate the patient: Make sure the patient or family caregiver understands how to take the opioid medication, how to wean off the opioid medication and what to do if the patient is experiencing adverse effects from taking or stopping the opioid medication.
- Recognize dependence: Each provider and his or her patient care team should be able to recognize signs of physical dependence and understand the basics of weaning opioids.
One of our collaborators in this study, Travis Rieder of the Johns Hopkins Berman Institute of Bioethics, wrote an account of his own struggles to wean off opioids. When he experienced days of withdrawal symptoms so severe that he frantically and desperately sought help, the only treatment his physician had to offer was another refill — a pitfall he narrowly escaped by holding out one more day. If his doctor had the proper training on how to correctly wean patients, Travis wouldn’t have been tempted against his better judgment to refill that prescription.
The HHS guide notes, “Clinicians have a responsibility to provide or arrange for coordinated management of patients’ pain and opioid-related problems, and they should never abandon patients.” I don’t believe abandonment of these patients is ever intentional. It comes from a lack of awareness and training. That conclusion won’t benefit patients who have already struggled through withdrawal symptoms to quit the drug. It’s too late for them, but it’s not too late for people who may be facing that challenge as part of their post-operative recovery. Now is the time to teach physicians how to properly wean their patients off opioids.
About the author. As performance improvement program director for pharmacy, Jim Lichauer is primarily responsible for developing and leading collaborative programs focused on medication safety and adverse drug events.