Slide Lecture with Audio
This activity is based on a 45-minute slide lecture presented by Dr. Howard Heit and Dr. Louis Kuritzky. This program is available as read only and with accompanying audio. If you are unable to access the audio portion of this presentation from your computer, this activity is also available on demand as a digitized replay via the telephone. To listen to the presentation, dial toll-free 800-642-1687 and enter activity code 20298376.
To complete this educational activity, the post-test can be accessed via the Program Components menu or the Testing Center link on the Princeton CME home page.
*Scroll to read lecture and/or follow along with audio.
Slide 1: Welcome to the teleconference, “Chronic Pain Management in Primary Care: Individualizing Pain Relief and Improving Quality of Life.” This program is jointly sponsored by the University of Cincinnati and Princeton CME, and is supported by an unrestricted educational grant from King Pharmaceuticals, Inc.
Slide 2: I am Dr. Howard Heit, Clinical Assistant Professor of Medicine at Georgetown University. I will be your presenter along with Dr. Louis Kuritzky, Clinical Assistant Professor in the Department of Community Health and Family Medicine at the University of Florida. He will be presenting a case study that will apply the data presented to a real-world scenario. Please note that all faculty disclosures for this program are included in the front of your activity booklet.
Slide 3: My goal in speaking to you today is to summarize the clinical and economic burdens of chronic, noncancer pain on patients and the healthcare system; identify common types of chronic, noncancer pain; outline multidisciplinary approaches for pain management and how to put into practice these multidisciplinary approaches; and last, but not least, describe the role of the pain specialist in pain management.
Please remember, to receive continuing education credit following the conclusion of this activity, each participant must complete the post-test and evaluation form located in the back of the activity booklet. These forms can easily be completed online for immediate receipt of credit at www.princetoncme.com. Thank you again for joining us. Dr. Kuritzky will now introduce the case study.
Slide 4: Thank you Dr. Heit. Let’s go into our case presentation now.
Slide 5: Our case is JR, a 58-year-old gentleman with type 2 diabetes who is coming in for his regular 3-month checkup. His medical history is positive for hypertension, dyslipidemia, and obesity, and current medications include metformin 1 g twice daily, insulin glargine 55 units daily, glimepiride 8 mg/day, lisinopril 40 mg/day, hydrochlorothiazide 12.5 mg daily, and atorvastatin 10 mg/day.
Slide 6: The objective findings indicate that the fasting sugar is 158, HbA1C is 7.6%, and glucose control has been progressively worse over the last 9 to 12 months even though insulin has been uptitrated. JR’s BMI is 32, which is concerning since it has increased over the last 2 years from 29. His blood pressure is borderline-adequate at 130/78, LDL is 88, and HDL is 45.
Slide 7: During JR’s office visit, we discuss with him that there are problems to address. There has been weight gain and glucose control is inadequate. At this point, JR reluctantly admits that he has struggled with his diet and exercise, and that actually his level of physical activity has decreased because he has pain in both of his legs.
Slide 8: When we review patient symptoms further with JR, he describes bilateral symmetrical burning leg pain for over 9 months’ time. Additionally, the leg pain worsens with exercise, and as a result he stopped his usual walking routine. Another factor that is impacting him is that the pain is worse at bedtime. It prevents him from sleeping and causes daytime drowsiness. He has already tried NSAIDs and acetaminophen, and the pain has not been responsive to either of those. As a result, JR feels discouraged.
Slide 9: The physical examination includes decreased vibration sense as determined with a 128-Hz tuning fork, decreased monofilament sensitivity, and bilaterally absent ankle jerks consistent with neuropathy.
Slide 10: At this point, a number of questions come up for consideration. First, what are obstacles that may impact our attaining the diagnosis? What treatment options are available for this patient, and if left untreated, how will this pain ultimately impact our patient?
I will now turn things back over to Dr. Heit for his presentation.
Slide 11: Thank you, Dr. Kuritzky. Chronic Pain Management in Primary Care: Individualizing Pain Relief and Improving Quality of Life.
Slide 12: Chronic pain is pain that has outlived its usefulness. Acute pain, I could accept; it is an adapted beneficial response necessary for preservation of tissue integrity. I touch a hotplate and remove my hand in order to prevent further tissue damage. But chronic pain serves no positive physiologic value. There is not one paper in the world literature that says chronic pain has a positive physiologic value. What is the value of a migraine headache, lumbar disk disease with sciatica, or metastatic bone cancer? It serves no positive value.
Slide 13: Pain can be classified as acute anticipated pain, such as for an elective dental procedure or an elective orthopedic procedure. Pain can be classified as acute unanticipated pain, secondary to a fall or to an automobile accident resulting in a hip fracture. Also, there could be chronic persistent pain or acute pain superimposed upon chronic pain.
Pain patterns of the patient should be discussed, such as their 24/7 pain pattern or breakthrough pain. You should always rate your patient’s pain at the initial evaluation and subsequent visits. One way to do this is numerically from 0 to 10—0 is no pain, 10 is the worst pain imaginable—or use the picture of a frown to a smiley face, depending on your patient population.
Slide 14: You always want to identify the type of chronic pain. Pain could be nociceptive pain, secondary to osteoarthritis causing joint pain or neck and back pain causing muscle spasms. Pain could be neuropathic in origin, such as neuralgia secondary to postherpetic zoster infection or peripheral neuropathy secondary to diabetes mellitus or alcohol. Pain could be a combination of both nociceptive and neuropathic pain, such as lumbar disc disease with sciatica.
Slides 15 and 16: One in 4 Americans suffer from chronic pain, with back pain one of the most common causes of long-term disability. Having said that, however, only a small percentage of these patients require opioid therapy and most could be treated with nonopioid medications or nonpharmacologic methods such, as exercise, physical therapy, behavior modification, or relaxation techniques.
Slide 17: Pain is the most common presentation to the primary healthcare professional. Fifty million Americans are undertreated for their pain syndrome. Thirty percent to 40% of patients with terminal disease die in needless suffering, secondary to the undertreatment of their chronic pain. Pain, when present, should be treated with medications approved by the FDA and consistent with state and federal regulations.
Slide 18: The impact of unrelieved pain is tremendous to our population. Unrelieved pain could be associated with depression, insomnia, anxiety, the inability to concentrate, or fatigue. This just mentions a few of the many symptoms of unrelieved pain.
Slide 19: Thirteen percent of the total workforce is affected with lost productivity secondary to pain conditions, and this costs the country over $60 billion per year—that is $60 billion per year.
Slides 20 and 21: The goals for treating chronic pain are to decrease pain, increase function and improve the patient’s quality of life, and use medicines that do not have unacceptable side effects. Approach to care should be flexible and multidisciplinary, depending on the needs of the patient. The treatment of pain is like a pizza pie, and opioid pharmacology may be just 1 piece of that pie.
Slide 22: You must educate the patient’s expectations early. The key message is partial relief of the pain results in a marked improvement of the patient’s quality of life, but it is unlikely that the pain management can make the patient pain free. The patient must understand their responsibility in pain management. The relationship of the prescriber and the patient is founded on mutual trust and honesty, which is based on boundary setting before writing the first prescription.
Patients, with the help of the prescriber, must establish realistic goals. I like to use sports metaphors in my practice. I tell the patient, “Pretend you are in the Olympics, and you are trying to achieve the gold, silver, and bronze medal. What is your number one goal? What is your gold medal that you want with appropriate pain management?” And this goal in a 70-year-old patient could be having their grandchild come to their home, sitting in their lap, and reading Dr. Seuss. Could you imagine the satisfaction that that patient has, to now be able to read to their grandchildren? That is the purpose of pain management.
Slide 23: What about the pharmacologic approaches to chronic pain management? We certainly have nonopioid analgesics and adjunctive analgesics. What is the definition of adjunctive analgesics? They were medications approved by the FDA to treat a certain disease or syndrome, but later on they were found to have analgesic properties and now are very valuable to use in rational pharmacotherapy in the treatment of chronic pain. And certainly, we have opioid analgesics.
Slide 24: The decision to try an opioid requires that the clinician possess the skills to perform an assessment of the pain, and the risks and benefits of opioid therapy, to optimize pharmacologic outcomes. The prescriber must be able to recognize, manage, or refer if abuse or addiction becomes part of the clinical picture.
Slide 25: What are the principles of opioid pharmacotherapy?
Slide 26: Short-acting or immediate-release preparations are used for acute pain or rescue doses for breakthrough pain. Modified-release opioids or opioids with a long half-life generally are preferred for chronic pain and improved treatment adherence. In my and my colleague’s experience, there is less pain fluctuation, better sleep, and reduced risk in those with addictive diseases using these agents. But having said that, this has yet to be documented in the peer-reviewed literature.
Slide 27: There is no one best opioid or opioid of choice. There is large individual variation in response to different opioids, which is based on the pharmacokinetics of the drug, the pharmacodynamics, or a new field called the pharmagenetics of the medication. Pharmacokinetics is what the body does to the drug, meaning the absorption, the metabolism, and the excretion of the drug. Pharmacodynamics is what the drug does to the body, meaning the effect of the drug. And pharmagenetics is the individual variation response to a specific drug. Let me give you an example: Codeine is a prodrug—10% of it is metabolized to morphine, which gives it its analgesic action. Codeine as a prodrug by itself has no analgesic activity. But one must know that approximately 10% of the population do not have the enzyme to convert codeine to morphine, and therefore, codeine would be ineffective in this population.
The decision to use one drug over another is based on the clinician’s experience; prior patient experience, meaning what worked for them; and practical considerations, including formulation availability, cost, and third-party payment. Certainly, you have to take into account the patient’s pain history, and that is why it is important to document their 24/7 pain or their breakthrough pain.
Slide 28: With opioid selection, we have immediate-release opioids, which come in 2 forms: combination products, which are opioids combined with acetaminophen and aspirin just to mention a few compounds, or single-entity drugs, such as morphine, oxycodone, hydromorphone, or oxymorphone.
Slide 29: We also have modified-release, sustained-release, or controlled-release opioids, which are immediate-release opioids in clever delivery systems. Again, these can contain morphine, oxycodone, fentanyl, oxymorphone, and there are others in development. Certainly, we have opioids with long half-lives, such as methadone or sublingual buprenorphine, which can be prescribed for off-label use for the treatment of pain.
Slide 30: I would like to say a few words about methadone. Methadone has a variable half-life from 12 to 120 hours and marked individual variation based on the patient’s pharmagenetics. Its potency may be greater than expected, secondary to it being an antagonist at the NMDA receptor site. Methadone has the potential to prolong the QT interval, resulting in cardiac arrhythmias in certain patients. It might be the best second-line opioid if dosed cautiously and carefully monitored. The bottom line with methadone, and all opioids, is to go slow and be conservative with your patient.
Slide 31: Methadone has a unique pharmacology. It is relatively inexpensive and can be safely and effectively used for chronic pain management. But you must know the following: The majority of deaths secondary to methadone, whether prescribed legally in a doctor’s office, whether it be in a methadone maintenance clinic for the disease of addiction, or illicitly used on the street, the deaths occur because the initial dose is too high, it is titrated up too fast, or there is drug-drug interaction.
Slide 32: Let me go into this a little bit in detail. If you have your patient on certain medications that cause induction of the cytochrome P-450 enzyme system, larger doses may be required when used in combination with these medications. Conversely, if you take someone off these medications, the methadone blood level will go up and the patient may experience sedation, and in the worst case, respiratory depression. So you must be aware of this. On the other side of the coin, if you have patients on medications that cause inhibition of the cytochrome P-450 enzyme system, smaller doses may be required when combined with these medications. Conversely, when you take someone off these medications, you may have to increase the methadone dose to maintain the pain relief and functional activities. The bottom line, for this reason, is that you always want to know all of the medications your patient is taking at any time.
Slide 33: Breakthrough pain should be treated. It is defined as a transitory pain flare that breaks through a baseline opioid regimen. It is recognized that breakthrough pain is associated with adverse consequences. The prescription of rescue doses should be considered on a case-by-case basis during opioid treatment of chronic pain. Rescue doses are usually immediate-release or short-acting opioids. There is an evolving role for new rapid-onset opioid formulations, such has the fentanyl lozenges or fentanyl buccal tablets.
Slide 34: You want to do dose titration over time, and that is critical to successful opioid therapy. There is no maximum or correct dose; however, no ceiling does not mean no limit. Whenever you increase the dose, you want a positive response of decreased pain and/or increased function, and you want to document this in the chart at all times. The doses should be gradually increased until pain relief is adequate or intolerable or unmanageable adverse effects occur. The term we used is titrate to effect.
Slide 35: The management of adverse effects is essential to optimize the benefit of opioid therapy. Common side effects include constipation, and you do not get tolerant to constipation. There are mu or opioid receptor sites throughout the GI tract, and constipation must be treated. Whenever you write a prescription for an opioid, you should always prophylactically tell the patient to take a stool softener, generally with senna or a wetting agent, to prevent constipation. It is the number one complaint of a side effect of opioid medication.
Sedation could occur when starting an opioid medication or increasing the dose, but usually this will go away in 4 to 5 days. Whenever I start an opioid for the first time, or I increase the dose to decrease pain and increase function, I tell the patient to be careful driving or operating heavy machinery. It will usually take 4 or 5 days for their body to get tolerant to the new drug or the increase of the opioid medication.
Less common side effects can be endocrine effects, nausea, sweating, itching, urinary retention, or headaches, and they all must be addressed if they are side effects in your patient.
Slide 36: Let’s talk about risk assessment and management during opioid therapy for chronic pain.
Slide 37: Prescription drug abuse has been rising, and now exceeds marijuana abuse
Slide 38: The cost of prescription opioid abuse in the United States is over $9 billion a year. Prescription opioid abuse is a significant public health problem.
Slide 39: To manage our patients, we must know the basic definitions of addiction, physical dependence, and tolerance. Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestation. It is characterized by behavior that includes one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and cravings (the 5 Cs).
Slide 40: Physical dependence is not addiction. Physical dependence is a state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation of the drug, rapid dose reduction, decreasing blood level of the drug, and/or the administration of an antagonist that blocks the action of the drug. Physical dependence and addiction can coincide, but physical dependence does not equal addiction in all cases.
Slide 41: Physical dependence is a natural neuropharmacologic phenomenon, like the sun coming up in the east and setting in the west, while addiction is both a neuropharmacologic phenomenon and a behavior phenomenon.
Slide 42: Say you take 99 people and put them in a room, and cancel their personal, professional, and social schedule for 2 to 3 weeks and divide them up. One group, you place on heroin. Another group, you place on controlled-release morphine, oxycodone, or oxymorphone. And the third group you place on prednisone or steroids. Within a matter of days, every person in that group will get physically dependent on the medicine that you gave them. Then you will taper them off the medication and not one of them—not one of them—will get the disease of addiction unless they have a genetic, social environment, or neurochemical disposition to the disease of addiction, and I emphasize the disease of addiction.
Slide 43: Tolerance is not addiction. Tolerance is a state of adaptation in which exposure to the drug induces changes that result in diminution of one or more of the drug’s effects over time. Key to this definition is all other conditions remain constant. Bad in your patient: the disease, the syndrome, the cancer is progressing, and you may have to increase the opioid medication and adjunctive medication. That is not tolerance. That is called disease progression. Good in your patient: the functional activity is increased and the patient’s quality of life has improved. To keep that improvement, you may have to increase the opioid medication and adjunctive medication. With doing that, you may even further improve their functional activity and quality of life. That is not tolerance. That is one of the principles of pain management.
Slide 44: Risk assessment is important for all patients considered for a trial of opioid medication. The question to ask is, “Is there risk and can it be managed?” The answer in the overwhelming majority of cases is yes it can be managed. If the decision is made to prescribe a controlled substance, set appropriate boundaries with consistent and thorough documentation in your medical records.
Slide 45: Triage is an important part of risk assessment. The primary care doctor has to ask himself or herself, “Who is my patient? Who is our patient? Who is your patient?” The primary care patient is the patient who has no history of addiction or psychiatric comorbidity. The primary care patient with specialist support is the patient who has a personal or family history of addiction or a stable psychiatric comorbidity. The referred patient to the pain management specialist, the addiction specialist, or the mental health specialist is the patient who you should not touch with a 10-foot pole, unless you are comfortable with him or her. That is the person who has an active addiction or an active, untreated psychiatric comorbidity.
Slide 46: Whenever you are writing and prescribing for a controlled substance, you must know the laws and regulations for prescribing a controlled substance. Opioid prescribing is acceptable, as long as it occurs in the usual course of a professional practice and it is for a legitimate medical purpose. What is a legitimate medical purpose? Let us say I am a dermatologist, and you come to my office to be treated for an itchy, oozy rash. As you leave my office, you turn to me and say, “I have a horrible migraine headache. Could you give me a prescription for an immediate-release opioid?” My answer to you under federal regulations would be, “No, I cannot. I am a dermatologist and I do not treat migraine headaches. And therefore, I should refer you back to your primary care doctor or a neurologist.”
Prescriptions should never be postdated. You should never write a prescription for a controlled substance on Monday and date it in the upper right-hand corner, Wednesday. This is against federal regulations for prescribing a controlled substance. When federal law or regulations differ from state law or regulations, the more stringent rule would apply. An example of this would be the following: In the state of Virginia, where I live and practice, a Schedule II prescription is valid for 6 months. In some states it is valid for 2 weeks. You must know how long it is valid in your particular state.
Slide 47: I would like to introduce to you a term called Universal Precautions in Pain Medicine. The term “Universal Precautions” originated from the infectious disease model of OSHA regulations, which were developed in the late 1970s to prevent the spread of infectious disease, secondary to AIDS, HIV, hepatitis B, or hepatitis C. It is a careful 10-point assessment of all persistent pain patients within a biopsychosocial model. There is appropriate boundary setting before writing the first prescription and a triage scheme, as stated, for estimating the risk for management and referral. By using this approach to the pain patient, stigma can be reduced, pain care can be improved, and overall risk of pain management can be reduced.
Slide 48: Let’s go over the 10 principles of Universal Precautions in Pain Medicine. And, as I go over these 10 principles, would they not apply to any patient you treat in your practice who has a chronic medical problem? Do you not want a diagnosis with an appropriate deferential? A psychological assessment, including the risk of addictive disorders? You want to have informed consent and have a treatment agreement, which could be verbal or written. A treatment agreement essentially says what I will do for you and what you will do for me, both based on mutual trust and responsibility. You want to have a pre- and postintervention assessment of pain level and function. How do you know where you want to go unless you document where you have been? Remember, I told you how important it is to do the rating of pain from 0 to 10 or frown to a smiley face. Would anybody start insulin to treat diabetes without getting a fasting blood sugar and a hemoglobin A1C? And therefore, you would not do this in pain management either. You want an appropriate trial of opioid therapy, generally with adjunctive medications, and it is just that: an appropriate trial to see whether this class of medications decreases pain and increases function. You want to continually reassess pain scores and level of function. Regularly assess the 4 As of pain medicine at each visit, meaning analgesia, activities, adverse effects, and any aberrant behavior. Periodically review the pain diagnosis and comorbid conditions, including addictive disorders. And last, but not least, document, document, document in your medical records. If you did not document it, it does not exist.
Slide 49: One could use certain assessment tools, such as the CAGE Questionnaire for alcohol and substance abuse. The CAGE Questionnaire is based on 4 simple questions: Have you tried to cut down or change your drinking or drug pattern? Have you been annoyed or angry by others concerned about your drinking or drug use? Have you felt guilty about the consequences of your drinking or drug use? Have you had a drink, or used a drug in the morning, such as an eye-opener, to decrease hangovers or withdrawal symptoms?
Slide 50: If your patient answers 2 of the 4 questions positive, then they have a current diagnosis of alcohol misuse or dependency with a sensitivity up to 94% and specificity up to 97%.
The NIAAA, the National Institute of Alcohol Abuse and Alcoholism, and the NIH recommend using the CAGE Questionnaire for all patients when considering prescribing a controlled substance.
Slide 51: Another risk tool is the Opioid Risk Tool. It is a 5-question clinical interview to assess patients and their risk. It was specifically developed to screen patients with chronic pain who will be using opioids and quantifies the risk according to low, moderate, or high. The 5 questions have to do with family history of substance abuse, personal history of substance abuse, age, history of sexual abuse, or psychological diseases. And please note, with a family history of substance abuse, it is weighted more toward the male. If the male has a family history of substance abuse, either in mom, dad, or grandparents, he has a greater chance 4-fold over the general population to get that disease himself. And notice, with sexual abuse it is weighted toward the female for obvious reasons.
Slide 52: What is the role of urine drug screens in pain practice? Urine drug testing is very useful in clinical practice. It is a consensual diagnostic test with full explanation and benefit to the patient. It provides objective documentation of compliance with a mutually agreed upon treatment plan, aids in the diagnosis and the treatment of the disease of addiction or drug misuse, and allows you to advocate for the patient, family, and social issues. I emphasize it is not for forensic purposes; it does not have chain of custody; it is not observed urine.
The initial testing is done with class-specific immunoassay drug panels, followed by gas chromatography and mass spectrometry. This will identify or confirm the presence of a specific drug and/or its metabolites. But you must know that immunoassay drug panels do not reliably detect synthetic or semisynthetic opioids. The immunoassay detects natural opioids, such as codeine and morphine. Gas chromatography and mass spectrometry are required for detection of synthetic opioids, such as methadone or fentanyl, or semisynthetic opioids, such as oxycodone or oxymorphone. If there are any questions about urine drug testing, always call the lab for help in interpreting the results.
Slide 53: What about an exit strategy for opioid therapy? If there is an entrance strategy for prescribing an opioid, there must be an exit strategy. When is it appropriate to give up on opioid therapy?
Well it may be based on circumstances, such as the emergence of an active substance abuse problem, persistent adherence problems to the treatment plan despite the treatment agreement and appropriate boundary settings, or lack of convincing benefit despite attempts at optimal therapy. It may be based on other aspects of a risk-benefit analysis, that the opioids cannot be tolerated at the dose that provides meaningful analgesia. The opioids do not decrease pain and increase function.
Slide 54: So in conclusion, chronic, noncancer pain places a heavy burden on the patient and the healthcare system. Utilizing a patient-centered multidisciplinary approach, primary care physicians can play a pivotal role in the management of chronic pain. By understanding how to manage opioids safely and effectively, physicians can prescribe a scheduled controlled substance approved by the Food and Drug Administration, consistent with state and federal regulations to give their patients the best quality of life possible given the reality of their medical condition. Remember, we are treating good patients with complex medical problems, not bad patients with complex medical problems.
Thank you. This concludes my presentations. We will now turn back to Dr. Kuritzky for a discussion of the case study mentioned at the beginning of this activity.
Slide 55: Thank you Dr. Heit. Let us go over the resolution of our case presentation.
Slide 56: You will remember that we had JR, the patient who was suffering from DPNP, diabetic peripheral neuropathic pain. There were a number of obstacles to attaining the right diagnosis. First of all, the clinician had never addressed DPNP with the patient, and the patient did not think it was important to bring his pain to the doctor’s attention. Additionally, JR was confused—he could not quite reconcile conflicting symptoms that he was suffering simultaneous burning and numbness in his legs.
Slide 57: The clinician then affirms for JR the good news: effective treatment options do exist. Neuropathic pain, however, often requires polypharmacy for successful resolution. The clinician has to consider the patient’s lifestyle when selecting a treatment regimen to minimize negative effects. The clinician suggests that JR start on an SNRI along with an opioid for breakthrough pain.
Slide 58: When JR is seen 8 weeks later, we have already titrated the SNRI to the most effective dose. JR’s pain has had a meaningful reduction, from 7 to 8 out of 10 down to 4 over 10. There has also been dramatic improvement in his sleep, and he is now able to return to his previous exercise program. JR is only using opioids for very occasional breakthrough pain at night, 1 to 2 times weekly. He has now lost 8 pounds because he can exercise once more without pain.
Slide 59: Chronic, nonmalignant pain syndromes, such as DPNP, can have marked effects in a number of areas including disease control, specifically diabetes, exercise, and sleep. Patients may sometimes be reluctant to bring up their pain symptoms for a variety of reasons, not the least of which may be simple confusion. Chronic polypharmacy, including opioids, may be required for good pain control.
Slide 60: Before we leave the discussion of JR’s case, it is important that whenever patients start taking opioid analgesics on a regular basis, clinicians have an appropriate exit strategy. Unfortunately, the literature is fairly wanting in exacting descriptions of appropriate discontinuation of opioid medicines. In addition, there are legal constraints that prevent clinicians who lack a specific license appropriate for detoxification to perform specific detoxification maneuvers. On the other hand, when patients no longer need to use chronic opioid therapy, it is fully appropriate to taper and discontinue opioids down to their appropriate therapeutic dose.
Generally, withdrawal syndromes are described as similar to a severe case of influenza, meaning that people who discontinue opioids, even abruptly, do not suffer the serious consequences such as seizures or even mortality that may be associated with other chronically used substances. That being the case, it is incumbent upon the physician to determine the best plan that will provide the least amount of discomfort while tapering down opioid analgesics.
Several plans have been offered and range from discontinuing at rates of 10% to 20% per day to 10% to 20% per week. In my own experience, I have generally offered patients, say, 1 month titration down, so discontinued at a rate of 25% per week. This has been found to be generally successful and palatable to the patient.
Thank you for your time. This concludes my presentation.
Next >>
