In this video Dr Anna Lembke discusses the importance of the velocity of tapering off opioids; don’t go too fast, don’t go backwards, it’s okay to take breaks, and let the patient determine the pace.
The mechanics of the opioid taper are easy definitely not rocket science but if the astronauts are not ready for the launch the mission will not be successful to prepare your patients for takeoff remember velocity and validation first the mechanics the most important thing to remember when tapering patients off of chronic opioid therapy in the outpatient setting
Is to go slowly medical journals commonly cite decreasing by 10% of the original dose per week but this is way too fast for many patients who have been on opioids long term the brain needs time to adjust to a lower dose of opioids and this adjustment can take months two years in some cases other important rules of thumb let the patient be involved in deciding how
Much to decrease and when studies demonstrate that people can tolerate higher levels of pain when they have some say over how and when it is inflicted compared with one another person inflicts the pain it’s okay to take breaks in the tapering process especially if the patient has an important event coming up and doesn’t want to be in low-grade withdrawal never
Go backwards i tell patients no matter how bad the withdrawal gets don’t go back up on the dose if you do you’ve lost all the hard work you put into adjusting to the lower dose this clinical purl comes from heather ashton who has written a definitive work on how to taper off of benzodiazepines her maxim of never go backwards applies equally well to tapering
Off of opioids a slow taper was crucial to laura’s ability to taper off of opioids she was initially tapered from 120 morphine milligram equivalents daily to 90 morphine milligram equivalents daily as part of her acute psychiatric hospitalization opioid tapers can be done much more quickly in the hospital but even so the process was painful for laura she was
Discharged on methadone 15 milligrams daily you needed two years to get all the way off of opioids you see how slow that is and the last little bit is typically the hardest the mechanics of the outpatient opioid taper are easy go slowly let the patient be involved in deciding on the pace take breaks and never go backwards now how do we psychologically prepare our
Patients that’s where validation becomes so important first validate how scary the idea of tapering is for many chronic pain patients on long-term opioid therapy don’t minimize their terror let them know that you know they’re afraid next prepare patients for what to expect and don’t sugarcoat it these are patients who will feel invalidated if their experience
Is worse than their expectations and pleasantly surprised if it’s not i know how scary this is for you but we’re in this together and i will support you through this journey i’m not gonna lie to you though this is going to be hard work opioid withdrawal can be very painful typical symptoms include vomiting diarrhea runny nose goosebumps and muscle spasms it can
Feel a lot like having a bad case of the flu in addition to physical symptoms you will also likely experience anxiety irritability insomnia and low mood but most importantly you’re going to have more physical pain even people without chronic pain can get full-body pain during opioid withdrawal for you it will likely be even worse since you have an underlying
Pain condition what is really important for you to remember though is that the increased pain is not an indication of progression of your underlying pain condition and not the pain you will have to live with off of opioids it is opioid withdrawal mediated pain indeed we can be very hopeful that when you are all the way off of opioids your pain will improve i
Don’t know doctor that sounds so hard it will be hard we’ll take it slowly and i’ll be there every step of the way one way to think of it is a little bit like undergoing chemotherapy for cancer i’m asking you to do a very difficult very painful thing at times it may even feel unbearable but when it’s over i am very optimistic that you will be in a better place
And feel much better than you do now every time you reduce the dose remind your patients that all the symptoms of opioid withdrawal will recur but reassure them that tincture of time alone will improve their symptoms finally never be stingy with the bravos you give your patients every time they are able to go down on their dose and give yourself a few bravos –
For encouraging your patient toward wellness along a thorny and seldom trod back you
Transcribed from video
Velocity and Validation of Opioid Tapers Matter By Stanford EdTech
