Art of the Wean

[Tramadeezy]

Long time lurker, first time poster. With all the opioid talk going on I wanted to get some input as to your guys' experiences and thoughts as to the best way to approach convincing patient's to wean their chronic opioids.
I just joined a group that does a fair amount of opioid prescribing. My plan is to stick to the CDC guidelines and keep/wean new patient's to <90 MME. I have begun the process with my mid-levels of approaching current patient's within the practice about weaning their opioid medications. A fair amount of these patient's are unfortunately on anywhere from 100-150 MME per day. We are very strict with UDS results/aberrant behavior etc... I feel like I have a decent approach to the "we are weaning your opioids" conversation but I find that the "stable" patient's on higher opioid doses without any shady behavior can be the most challenging because "they have been on these medications for years".
Any tips on how to approach these patient's? Should I just have a "we are weaning your medications so deal with it" type approach? Is it justifiable to continue higher MME per day with patients who have been relatively stable/compliant over the years? Any input appreciated, thanks.

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[lobelsteve]

One size does not fit all.
But literature sulports 3-9 fold increase risk of mortality over o0 meq.
So 5 pills fewer per month until at 90meq.

 

[Aether2000]

90 mg MED is still too high for those drinking alcohol, even occasionally (52% of the population drinks regularly and just because they take opioids doesn't mean they feel they cannot drink alcohol), for those on benzodiazepines, for those with sleep apnea or who those who are morbidly obese, have hepatic or renal dysfunction, for those taking methadone, or other conditions that suppress respirations. Weaning down is not a negotiable issue- it must be mandated then implemented immediately once the decision is made. Reassuring the patient that for 80% of patients after weaning, their pain will actually improve. Wean down by 5% per week for minimal withdrawal but may do up to 25% per week in some. Methadone usually requires a 2-3 month wean.

 

[drusso]

Dear (insert patient name):

(Insert your practice name)is committed to providing chronic pain treatments that offer the greatest benefit at the lowest possible risk to the patient. As a result of this commitment, we are closely monitoring the effectiveness and dose of opioid medications prescribed to our patients.

You are receiving this letter because you are receiving opioid medication at a level which may be adding an increased level of risk for opioid use disorder, overdose, or death without an associated clinical benefit.

At your next medication follow-up visit, you and your provider will discuss the options available to you to assure that you are receiving the lowest effective dose of opioid medication. You will have the choice of working with your current provider to reduce your dose over a period of time or enrolling in our opioid reduction and symptom management program. This program will require you to attend more frequent appointments, provide regular urine drug screens, attend pain education classes, meet with a behavioral health team member and undergo a formal chemical dependency evaluation, develop a safety plan around the use of your medication, and commit to use additional treatment options such as physical therapy, guided imagery, mindfulness/stress reduction tools, or other interventional therapies.

Please be prepared to discuss the above information with your provider at your next appointment. In the event that you cannot coordinate an appoint with our office to review the contents of this letter, then one will be assigned to you. At your request we can also coordinate your chronic pain management care back to your primary care provider or other health care practitioner that you designate.

In good health,

(Insert your name)
Medical Director.

 

[willabeast]

The trick is getting the patients to agree. I just told them it was guv mandated, not their fault. Weaning is simple - one less pill (per day) each refill or if large long acting single pill convert to multiple long acting same dose and then one less pill (per day) each refill.
example - patient on methadone 60 mg q 12 hours (on 10 mg pills). cut down to 50 mg in AM, 60 mg in PM. next refill 50 AM 50 PM. next refill 40 AM 50 PM next refill 40 AM 40 PM. keep going until at guv mandated opiate dose. this is a slow wean, but it makes for uncomplicated directions is easy to follow the directions and a slow wean is easier on the patient and patient family. norco 10/325 same way. if on ii po qid, then next refill cut back to 7 a day, next refill ii po tid, next refill #5 a day, next refill ii po bid, and so on.

 

[drusso]

The trick is getting the patients to agree. I just told them it was guv mandated, not their fault. Weaning is simple - one less pill (per day) each refill or if large long acting single pill convert to multiple long acting same dose and then one less pill (per day) each refill.
example - patient on methadone 60 mg q 12 hours (on 10 mg pills). cut down to 50 mg in AM, 60 mg in PM. next refill 50 AM 50 PM. next refill 40 AM 50 PM next refill 40 AM 40 PM. keep going until at guv mandated opiate dose. this is a slow wean, but it makes for uncomplicated directions is easy to follow the directions and a slow wean is easier on the patient and patient family. norco 10/325 same way. if on ii po qid, then next refill cut back to 7 a day, next refill ii po tid, next refill #5 a day, next refill ii po bid, and so on.

Agree with scape-goating the government except I say that it was due to Obama, Elizabeth Warren, and Nancy Pelosi.

 

[willabeast]

Agree with scape-goating the government except I say that it was due to Obama, Elizabeth Warren, and Nancy Pelosi.

This would not work well with Liberal leaning patients. Remember that poor doc who got shot recently.

 

[kstarm]

I agree that one size doesn't fit all. For really stable patients without concerning behaviors I offer more choices as to if they would prefer to decrease dose or decrease frequency. I am not too concerned with how we get to our goal of being off the medications as long as we get there (If the doses are super high then I will be more directive). Sometimes I will prolong the weaning schedule if the patient is actively engaged in multidisciplinary care. The messaging I think that is important is that they often will notice a change in the medications, including increased pain that will improve with time, and they may notice more mental health issues (anxiety, depression, behaviors) again a normal part of the process. This improves over time, and as Algos pointed out the vast majority of patients feel the same or better once off of the medications and their body has adjusted. I often talk about hyperalgesia as well, and ask how does their pain now compare to how it was a year ago or longer. Usually it is about the same or worse despite escalating doses of opioids.

 

[deleted185747]

Expect your negative online reviews to state "Doc only cares about following rules and doesn't care about his patients true needs"

 

[Tramadeezy]

Appreciate all the input. I find myself using a lot of these tactics i.e blaming the CDC/FDA, opioid epidemic, hyperalgesia etc which seems to help quite a bit. At the end of the day I'm just gonna have to stick to a strict weaning policy and set expectations early for new patients because if I see one more national news story about the opioid epidemic (just watched one) I might just hang up the prescription pad for good...

 

[melancholy]

Print out that line chart showing the dose to risk correlation and maybe a few articles showing improvements in pain intensity and functioning after tapering. Laminate the chart and keep it around your desk. Can even put some propaganda on your exam room walls and post up that chart next to them. Leverage family members and bring up the risk issues.


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[painfree23]

90 mg MED is still too high for those drinking alcohol, even occasionally (52% of the population drinks regularly and just because they take opioids doesn't mean they feel they cannot drink alcohol), for those on benzodiazepines, for those with sleep apnea or who those who are morbidly obese, have hepatic or renal dysfunction, for those taking methadone, or other conditions that suppress respirations. Weaning down is not a negotiable issue- it must be mandated then implemented immediately once the decision is made. Reassuring the patient that for 80% of patients after weaning, their pain will actually improve. Wean down by 5% per week for minimal withdrawal but may do up to 25% per week in some. Methadone usually requires a 2-3 month wean.

For methadone wean, let's say 30 mg q6h , when u say 2-3 months , how r you adjusting at each visit?

 

[Aether2000]

Since 120mg methadone = 1440mg morphine (Washington Agency Directors), that is a very high dose to start off with. In such cases, I wean weekly by converting to a combination of 5 and 10mg tablets then give a printed schedule. The ultimate goal is to be at or below 20mg methadone a day (80 mg morphine equivalent) so reduction would be 100mg methadone over 13 weeks or roughly 5-10mg a week. The other option is halving the pills with a pill cutter initially. For the first dose to be reduced, I have them select the time where the pain is usually less and take 15mg instead of 20mg only for that one dosage. This small reduction is a baby step, to prove to them they can reduce the dosage, then thereafter I reduce by 10mg a day and hold at that level for a week before reducing more. Adding gabapentin, tizanidine, clonidine, etc as needed for withdrawal prevention is frequently needed with methadone dosage reduction. Withdrawal symptoms from methadone will persist for months (up to 6) after reaching the target. Of course optimally, converting from methadone to another opioid would be preferable since methadone has a death rate nearly 10 times higher than any other opioid, ostensibly due to its auto-inhibition of the 3 hepatic metabolic pathways, which is the reason the Agency Directors have correctly determined methadone has a very high MED.

 

[lobelsteve]

Since 120mg methadone = 1440mg morphine (Washington Agency Directors), that is a very high dose to start off with. In such cases, I wean weekly by converting to a combination of 5 and 10mg tablets then give a printed schedule. The ultimate goal is to be at or below 20mg methadone a day (80 mg morphine equivalent) so reduction would be 100mg methadone over 13 weeks or roughly 5-10mg a week. The other option is halving the pills with a pill cutter initially. For the first dose to be reduced, I have them select the time where the pain is usually less and take 15mg instead of 20mg only for that one dosage. This small reduction is a baby step, to prove to them they can reduce the dosage, then thereafter I reduce by 10mg a day and hold at that level for a week before reducing more. Adding gabapentin, tizanidine, clonidine, etc as needed for withdrawal prevention is frequently needed with methadone dosage reduction. Withdrawal symptoms from methadone will persist for months (up to 6) after reaching the target. Of course optimally, converting from methadone to another opioid would be preferable since methadone has a death rate nearly 10 times higher than any other opioid, ostensibly due to its auto-inhibition of the 3 hepatic metabolic pathways, which is the reason the Agency Directors have correctly determined methadone has a very high MED.

I have zero methadone patients. I do not like the drug due to death rate as compared to other opiates and no data suggesting better efficacy. Weaning methadone is always a bad idea. Keeping someone on it for pain is probably the only thing worse. Playing it safe is to wean to 60mg per day then induce. Either way, turf to Addictionology.

 

[melancholy]

Since 120mg methadone = 1440mg morphine (Washington Agency Directors), that is a very high dose to start off with. In such cases, I wean weekly by converting to a combination of 5 and 10mg tablets then give a printed schedule. The ultimate goal is to be at or below 20mg methadone a day (80 mg morphine equivalent) so reduction would be 100mg methadone over 13 weeks or roughly 5-10mg a week. The other option is halving the pills with a pill cutter initially. For the first dose to be reduced, I have them select the time where the pain is usually less and take 15mg instead of 20mg only for that one dosage. This small reduction is a baby step, to prove to them they can reduce the dosage, then thereafter I reduce by 10mg a day and hold at that level for a week before reducing more. Adding gabapentin, tizanidine, clonidine, etc as needed for withdrawal prevention is frequently needed with methadone dosage reduction. Withdrawal symptoms from methadone will persist for months (up to 6) after reaching the target. Of course optimally, converting from methadone to another opioid would be preferable since methadone has a death rate nearly 10 times higher than any other opioid, ostensibly due to its auto-inhibition of the 3 hepatic metabolic pathways, which is the reason the Agency Directors have correctly determined methadone has a very high MED.

From what I recall, converting from methadone to oral morphine equivalents doesn't have the same changing dose ratio that is seen when converting varying levels of morphine to methadone. Seems a bit of a simplification to use same conversions both way, but I suppose their goal is to taper down anyway and at that high of a dose, will prob start with similar protocols.


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