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[drusso]

Opioid Tapering or Discontinuation vs No Change for Opioid Overdose or Suicide

This comparative effectiveness study examines the association of opioid tapering or abrupt discontinuation with opioid overdose and suicide events among patients receiving a stable long-term opioid dosage without evidence of opioid misuse.

jamanetwork.com

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[kstarm]

I thought this was old news. People are more vulnerable during opioid tapering, that is well known. The question becomes is the risk of tapering greater than or less than the risk of being on long-term opioids. There are a number of reasons to taper besides misuse.

 

[Ducttape]

study looked at whether there was harm with opioid tapering.

obviously there was a finding, as kstarm pointed out above.



the statistical numbers are exceedingly small to draw conclusions and they have a huge number for stable dosing vs a small number of patients who were tapered.

a very small change in the tapered group seems to lead to bigger percieved effects.

87% were stable dose. 11% were tapered.
the difference in suicide rate was 0.96% amongst stable dose patients vs 1.10%, meaning the risk difference was 0.15%. meaning what, 1 person in 666 people? or in their 199 836 study group, maybe 33 people?

regardless, i am in agreement that patients who are at stable doses who are not misusing - and who are not exhibiting major adverse side effects of the opioid - should not be tapered.

 

[kstarm]

regardless, i am in agreement that patients who are at stable doses who are not misusing - and who are not exhibiting major adverse side effects of the opioid - should not be tapered.

Sure, but MME also carries risk. I recently had a patient referred to me on 240mg of oxycodone a day for cancer related pain. Cancer had been in remission for over 20 years and pcp kept her on the dose. No aberrancies, no misuse, no change in dosing. She shows up at your clinic and your next step is what? You would continue? You would tell referring doctor that regimen is appropriate?

 

[lobelsteve]

Sure, but MME also carries risk. I recently had a patient referred to me on 240mg of oxycodone a day for cancer related pain. Cancer had been in remission for over 20 years and pcp kept her on the dose. No aberrancies, no misuse, no change in dosing. She shows up at your clinic and your next step is what? You would continue? You would tell referring doctor that regimen is appropriate?

So what pain are they treating? Post CTX? Neuroma?
What is expectation?

If nothing there, then risk assessment and tell PCP ok to continue doing what they have been doing. Treat it like risk stratification and not take over.

 

[callmeanesthesia]

But wait, we are ignoring the most significant line in the whole abstract: “No significant difference in outcomes between abrupt discontinuation and stable opioid therapy was identified.”

 

[kstarm]

So what pain are they treating? Post CTX? Neuroma?
What is expectation?

If nothing there, then risk assessment and tell PCP ok to continue doing what they have been doing. Treat it like risk stratification and not take over.

I guess I am surprised you would greenlight 240mg of oxycodone a day for really any condition. How high do you go? In her case there wasn't a specific pain they were treating, she got put on them when she was actively going through cancer treatments and then never stopped.

 

[lobelsteve]

I guess I am surprised you would greenlight 240mg of oxycodone a day for really any condition. How high do you go? In her case there wasn't a specific pain they were treating, she got put on them when she was actively going through cancer treatments and then never stopped.

Not green lighting. Had same referral come in today. 270 meq. Oxy 15 qid. Perc 10 qid. At same time. In remission for years. Nurse flagged it. Declined consult. Not my circus, not my monkeys.

 

[kstarm]

Not green lighting. Had same referral come in today. 270 meq. Oxy 15 qid. Perc 10 qid. At same time. In remission for years. Nurse flagged it. Declined consult. Not my circus, not my monkeys.

I hear you about screening and we try hard to catch these as well but "Not my circus not my monkey" is avoiding the question. Lets say for argument the consult is missed and ends up in your office, or PCP calls you up to run a case by you about how he/she should handle the patient they are inheriting from retired doc. High dose opioids, chronic pain, no aberrancies, no dose escalation, none to minor side effects, limited to moderate pain relief but patient doesn't want to stop. You recommend continuing regimen?, rotation to bupe?, tapering? We are currently getting requests to see a number of similar patients with local pain doc retiring recently.

 

[lobelsteve]

I hear you about screening and we try hard to catch these as well but "Not my circus not my monkey" is avoiding the question. Lets say for argument the consult is missed and ends up in your office, or PCP calls you up to run a case by you about how he/she should handle the patient they are inheriting from retired doc. High dose opioids, chronic pain, no aberrancies, no dose escalation, none to minor side effects, limited to moderate pain relief but patient doesn't want to stop. You recommend continuing regimen?, rotation to bupe?, tapering? We are currently getting requests to see a number of similar patients with local pain doc retiring recently.

If not in palliative care I recommend tapering. No benefit from high dose therapy compared to lower dose therapy with risk of unintentional OD above 80-90 meq.
Patient and provider have full understanding that I am not going to be writing the Rx.


For retiring doc scenario: don’t pick and choose. Take none. I have blanket refusal to see patients from local docs who are/were running pill mills.

 

[Agast]

For retiring doc scenario: don’t pick and choose. Take none. I have blanket refusal to see patients from local docs who are/were running pill mills.

It’s not that simple. When you’re in private practice you keep a somewhat cordial relationship with your referring PCPs. Being snarky with a blanket No is not going to fly with those doctors. At the very least you go through the motions of a chart review and justify each patient you are not accepting.

 

[lobelsteve]

It’s not that simple. When you’re in private practice you keep a somewhat cordial relationship with your referring PCPs. Being snarky with a blanket No is not going to fly with those doctors. At the very least you go through the motions of a chart review and justify each patient you are not accepting.

The PCPs in practice are not the problem or they are the problem. If they are the problem, then no works well. If they need help and are not the problem then see their patients.

The problem doc: practicing pain as an ophtho, Ob/gyn, FP. Continuing regimen from someone else for 5 years then deciding to turf, Opi/BZD combo.

 

[Ducttape]

I keep a cordial relationship with them by offering services as a consultant.

Focus on the consultant aspect for these patients.

It's up to the PCP to use the plan you suggest including continuing or reducing medications.

 

[epidural man]

Posts that didn’t age well?

Click my handle, then click on “posts”.

I’m pretty sure nothing I’ve said in the last 10 years has aged well.