The Risks of Opioid Tapering or Rapid Discontinuation
The 2017 Canadian Opioid Guideline was released in May 2017 after extensive literature reviews and consultations with Canada’s leading experts in safe opiate prescribing for patients with chronic (ie non- end-of-life) pain. Our earlier belief that “there is no ceiling dose” for these powerful drugs has been blighted by the recognition of harms which include unintended overdoses and deaths. Wisely, the 2017 guideline recommends lower starting and ceiling doses of opioids, and focuses on tapering higher doses as well as avoiding them entirely in patients with substance use disorders or psychiatric co-morbidities.
We agree that gentle and carefully managed tapers of high dose opioids can be effective in reducing these riskier doses. Many patients endorse feeling better at lower doses. Unfortunately, chronic pain, addiction and opioid management skills for most healthcare providers remains inadequate.1
The 2017 guideline focuses entirely on reducing opioid doses, yet makes no mention of the risks of opiate withdrawal. By adopting the guideline as a standard of practice, prescribers might taper people too rapidly or cut them off entirely. Many family MD’s have refused to prescribe opiates or even take chronic pain patients into their practices. Nor do they have training in how to recognize withdrawal symptoms or manage the risks associated with the adrenergic and autonomic overdrive of opiate withdrawal.
Most healthy people will just feel unwell during withdrawal. Symptoms include sweating, nausea, myalgias, diarrhea and vomiting. However, some populations: pregnant women, the elderly, the medically complex (e.g. with heart disease) or psychiatrically unstable may suffer severe complications including miscarriage, myocardial infarction or suicide. Others may seek opiates on the street and be exposed to unknown substances including fentanyl or carfentanyl. Overdose deaths in people who have lost their opioid tolerance, for example, prisoners recently released from jail have risen.2,3
Programs like Project ECHO, the Atlantic Pain or Medical Mentoring for Addictions and Pain Networks can support healthcare providers who are usually self-selected.4We believe that the guideline committee needs to urgently revise this oversight and disseminate it widely to ensure that safety trumps policy. Everyone dying of unintended overdose was someone who deserved compassionate and best-practice care. Let’s not create a secondary opioid crisis due to unskilled and overzealous de-prescribing.
References
1. Dubin et al. 2010. Cross-Canada Checkup 2010 : a survey of Family Medicine Residency training in chronic non cancer pain (CNCP) and addiction. Pain Res. Manage (ABS) 16 (2):105.
2. Binswanger et al. 2007. Release from prison – a high risk of death for former inmates. NEJM 356:157-165.
3. Lynch ME and J. Katz. 2017. “One Size Fits All” Doesn’t Fit When It Comes to Long-Term Opioid Use for People with Chronic Pain. Can. J. Pain 1: 2-7.
4. Katzman et al. 2014. Evaluation of American Indian Health Service Training in Pain Management and Opioid Substance Use Disorder Am. J. Public Health. 2014. 1356-1362
