How to de-prescribe and wean opioids in general practice
Over the last 10-15 years, many adult patients with chronic non cancer pain (CNCP) have been started on opioids to assist with pain management. Current evidence does not support the long term prescription of opioids for CNCP .
In fact, there is little evidence of reduction in pain intensity or improvement in function, and increasing evidence of harm. As a result, it is best not to consider using opioids to manage CNCP and de-prescription, and weaning is increasingly appropriate. The question is: How do you do this? Gradual reduction needs to be adjusted to the person, their history, their experience as the medications are reduced, and the concurrent acquisition of self-management skills. A slower or faster wean may be chosen accordingly.
General recommendations
- a faster wean might reduce the daily opioid dose by 10-25% each week, or even each day if high risk of opioid harm
- a slower wean might reduce the daily opioid dose by 10-25% each month according to patient tolerance
- Develop a GP plan for pain management
- Suggest convert to one medication: http://fpm.anzca.edu.au/resources/professional-documents or download the free app.
- Tailor the reduction to each patient, decreasing at a rate that allows the patient to manage any withdrawal symptoms. Some patients may tolerate a faster deprescription programme
- Follow up regularly
- The ultimate goal is to cease completely
- Support your patient to learn active self-management skills (psychological, physical, lifestyle, social)
- If necessary get help from a pain and/or addiction specialist.
Your patient may present in a number of ways
JH is a 50-year-old man who presents with his wife for advice. He was commenced on opioids after a serious motor vehicle crash with pelvic fractures. Now 6 months later he is on 60mg oxycodone modified release a day. He and his wife are keen to stop the medication immediately as he finds it affects his ability to concentrate at work and that the medication has changed his personality and sex drive. You discuss the risk of immediate cessation and the potential failure associated with rapid withdrawal. You discuss the benefits of ceasing, and advise a tapering plan with 2 reduction steps each week to limit the likely symptoms of withdrawal.
JH decides to give the plan a try and takes 3 weeks off work to do this. You review him weekly to assess his progress. He finds that he has some troubling symptoms particularly insomnia and some pain, however he manages this with exercise, stretching and meditation. 1 month later, he has ceased his medications and feels his symptoms have settled and reports feeling much better.
Note: Some patients find abrupt cessation works very well. As a result, it may be worth offering this as an option. However, there is a risk of significant withdrawal symptoms associated with this approach , so check with the patient how they have feel if they miss a dose to get a sense of their risk of troubling withdrawal affects, warn about the possibility of withdrawal and follow up closely so you can assist them to wean the medication.
Seek assistance from a pain specialist/addiction specialist as required
PF is a 42-year-old woman, working as a primary school teacher. She started on opioids due to pelvic pain 1 year ago. She is now on hydromorphone (modified release) 8mg daily. She was previously on codeine/paracetamol combination and oxycodone. She notices that she is very constipated and lightheaded at times. She is finding it hard to concentrate at work and is not getting out and doing activities she previously enjoyed on weekends. She used to enjoy long distance ocean swimming. She attends your surgery to ask you about changing the medication.
Together you decide to slowly decrease her dose using a monthly step down. At the same time, you refer her for counselling and encourage her to actively manage her pain using exercise and pacing.
She changes back to oxycodone modified release and continues to slowly decrease the dose. You see her often to offer support and encourage her to get back to swimming. She slowly builds up her swim fitness. She finds benefit from meditation. She ceases her medication over four months.
Note: patients who have recognised that the medication isn’t working or is causing side effects are generally ready to begin the process of weaning and ceasing their medication. This doesn’t mean that they will be able to do this easily. They usually need ongoing support and a gradual tapering of the medication, as well as a plan to manage their pain with active non pharmacological tools and perhaps non-opioid medications.
MP is a 36-year-old woman on a daily dose of 120mg oxycodone modified release following a back injury in the workplace 5 years ago. You have been discussing the process of cutting down her dose, as it has become clear that the opioids are not assisting her to manage her pain or improving her function. She has been trying to cut the dose down by 10mg, a week but finds that she gets severe symptoms when she tries to decrease.
You plan a slow reduction of 10mg a month and see her 2nd weekly for ongoing support. She starts physiotherapy and attends a meditation class which she finds very helpful. After 6 months, she is on 60mg and notices that her pain is improved. She feels more confident about her ability to stop the opioids and continues to wean, ceasing over the next six months.
Note: For many patients, reduction of opioids can be difficult with troubling withdrawal affects. In addition, the fear of being overwhelmed with pain and previous unsuccessful attempts can decrease the patient’s confidence that they can manage. Don’t underestimate how useful ongoing support and therapeutic alliance with the patient is.
JM is a 25-year-old rugby player you see in your general practice 1 week after discharge from hospital following a knee reconstruction. He is feeling deeply disappointed that he is out of the game for the rest of the season. He requests more Endone. You explain that Endone is for short term management and the risks of ongoing use. Together you develop a plan for managing his pain and use a combination of physiotherapy, non-opioid pain relief and a few weeks of Endone only prior to physiotherapy sessions.
3 weeks later he has ceased the Endone and he and his physiotherapist are happy with his progress.
Note: If opioids are used for the pain of acute injury, it’s important to give clear direction about anticipated duration of therapy. Often this is a matter of days to weeks, on a limited dose up to a maximum of 90 days in complex cases.
JS is a 48-year -old woman who comes to see you for the first time. She has been treated with modified release oral morphine 60mg 5 times a day for the last 10 years. She is unwilling to consider changing her medication and becomes angry and tearful when you suggest that you are concerned about her current medication regime. She doesn’t take any other medications and doesn’t consider that her medication is a problem. She lives with her 12 year old son, husband and mother in law, who manages the household as JS is too unwell to do very much around the house. She spends most days resting on the sofa watching TV.
She has tried non opioid pharmacotherapies, counselling, and manual therapies and found no benefit. She claims that the multidisciplinary pain clinic has suggested in the past that her current treatment is appropriate. She hasn’t escalated her dose in the last 5 years. Pain scores suggest that her pain is being poorly managed with her current treatment regime.
She tearfully says that you are treating her like ‘a junkie’ and she has a legitimate pain condition and needs her medication to function. You explain that you are only able to assist her with ongoing multidisciplinary pain clinic support and suggest a case conference with the local pain clinic and are only able to prescribe for her if she re-attends the pain clinic, visits the pharmacy weekly to collect a week’s medication, and begin a slow reduction in her dose at a time to be negotiated, with supported adoption of self-management strategies.
She reluctantly agrees to this. You note the plan in her file. She then cancels her next appointment. The pharmacy rings to let you know that she has presented to the pharmacy with a script from another doctor. She has transferred to another doctor. You note the transfer to another doctor and practice in her file.
Note: patients who are unwilling to engage in active self-management can be difficult to manage. Bear in mind that you need to make an assessment whether you consider it safe to prescribe, and if you are concerned about this, you’re under no obligation to do so. It is however important to offer the patient other reasonable options. Get support and help from your specialist pain and or drug and alcohol teams. It is anticipated that the introduction of an Electronic Real Time Reporting and Monitoring system will provide a framework for improved management of such patients.
HJ is a 36-year-old man with schizophrenia, morbid obesity, asthma, hypertension, alcohol dependence and chronic lower back pain. Your practice has seen him and his family over many years. His management has always been difficult. His medications include, quetiapine (slow release) 400mg nocte, diazepam 15mg BD, salbutamol inhaler, fluticasone/salmeterol (500/50), ramipril 10mg, 50mg oxycodone modified release BD. His schizophrenia is unstable and he has multiple admissions for psychosis. He was recently brought into the emergency department by ambulance after he was found unconscious on the street. He is admitted to ICU and diagnosed with accidental multi-substance overdose. He undergoes alcohol detoxification. The quetiapine and oxycodone are ceased in hospital and he is commenced on buprenorphine/naloxone combination for opioid dependence and depot zuclopenthixol. You are contacted as part of discharge planning and he is followed up in the community by the mental health and drug and alcohol team. His family notice that he seems less distressed with the change in medication. You continue to see him and his family in your practice and liaise with the mental health and drug and alcohol teams and he returns to your care once he has stabilised. You are happy to continue prescribing his medications with support from the specialist teams.
Note: the use of opioids alone and in combination with other Central Nervous System depressants increases the risk of potentially fatal overdose. This patient is complex and requires specialist support.
