A substantial number of Americans are receiving opioid medications for chronic pain. In 2016, increasing concerns about the risks of these medications led the Centers for Disease Control to develop guidelines that included a recommendation to avoid prescribing dosages above 90 morphine milligram equivalents (MME) per day. Some interpreted this recommendation to mean that individuals who were already prescribed higher dosages should have the dosage reduced, leading to forced precipitous tapers and reports of harm associated with this practice. In response to this, the US Department of Health and Human Services has issued a guide on “appropriate dosage reduction or discontinuation of long-term opioid analgesics” that includes the following recommendations:
- “Avoid insisting on opioid tapering or discontinuation when opioid use may be warranted.”
- “Avoid misinterpreting cautionary dosage thresholds as mandates for dose reduction.”
- “If a patient exhibits misuse behavior or other signs of opioid use disorder” and “criteria for opioid use disorder are met (especially if moderate-severe), offer or arrange for medication-assisted [sic]* treatment.”
- “If patients on high opioid dosages are unable to taper despite worsening pain and/or function with opioids, whether or not opioid use disorder criteria are met, consider transitioning to buprenorphine.”
* AOD Health (and the National Institute on Drug Abuse) recommend use of accurate, non-stigmatizing terminology, such as “medication for opioid use disorder,” “medication for addiction treatment (MAT),” or simply “medication,” in lieu of “medication-assisted treatment.”
Comments: This guide is a much-needed clarification that emphasizes a patient-centered approach to helping individuals who have been prescribed opioids for chronic pain. It also advocates for expanded use of buprenorphine to include individuals at high risk who do not necessarily meet criteria for opioid use disorder. Although prescribing opioids—particularly at high doses—should be avoided, we should not punish patients who are in this situation.
Darius A. Rastegar, MD
Reference: The U.S. Department of Health and Human Services Working Group on Patient-Centered
Reduction or Discontinuation of Long-term Opioid Analgesics. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. October, 2019.