Workers’ compensation claims organizations that incorporate tapering as part of an aggressive opioid management strategy can minimize risks to patients receiving long-term opioid therapy and keep claim costs in check. Long-term opioid therapy for treating chronic pain carries significant risks and can lead to complex, escalating and expensive medication regimens that carry their own risks — and in many cases prevent patients from returning to work. When the high number of fatal overdoses involving prescription opioids is considered, the need for opioid tapering becomes even more important. In 2010, almost 17,000 such deaths were recorded.
Tapering and discontinuation of opioid therapy is an intensely individualized process that depends largely on patient-specific factors. No single method works best, although all tapering protocols recommend against abrupt discontinuation of opioid therapy. Best practices and recommendations from reputable sources should be considered when selecting a tapering protocol and rate of reduction. The spring 2014 issue of the RxInformer clinical journal published by workers’ compensation PBM Healthesystems provides a comprehensive reference for claims organizations that summarizes current evidence-based tapering guidelines. The article, “Opioids: A Guide to Tapering and Discontinuation,” authored by clinical pharmacists with expertise in pain management:
- identifies steps to take before beginning a tapering process
- guides patient selection
- discusses withdrawal symptoms
- includes consideration of adjunctive therapies
- identifies circumstances that warrant referral of the patient to others
According to Robert Goldberg, MD, FACOEM, an occupational medicine specialist and chief medical officer at Healthesystems, “Opioid dose tapering and eventual discontinuation should be seriously considered whenever feasible. Long-term opioid users frequently become tolerant of opioids and require increasingly higher doses to achieve pain relief. High doses for prolonged periods can cause side effects that require additional medications to control. Therefore tapering is a key to pain management.”
Most patients can taper off opioids. Ideal candidates are:
- Patients taking high doses of opioids, regardless of whether they are long-acting or immediate-release formulations. Depending on the guideline followed, high doses refers to daily morphine equivalent dose (MED) over 50-120.
- Patients who show no improvement in functional gains despite continued therapy.
- Patients whose pain has increased or shows no modification despite dose increases.
Gradually reducing a patient’s MED can open up the possibility of an injured worker discontinuing opioid therapy and returning to work and a productive lifestyle.
Payers may need to adjust current opioid management policies to include alternative therapies to help injured workers discontinue opioid therapy.
Dr. Goldberg explained, “Alternative therapies such as cognitive behavior therapy can promote successful dose tapering when used as an adjunct to pharmaceutical therapies. Referral to a mental health professional for cognitive behavior therapy can teach coping skills and reduce the anxiety that often accompanies the tapering process.”
Since the new American College of Occupational and Environmental Medicine (ACOEM) opioid treatment guideline reduced the maximum recommended daily MED to 50 from the 110-120 MED that was previously thought safe, opioid dose tapering may play a more prominent role in treatment as physicians and payers seek to bring patients’ drug therapy in line with the new recommendation.
About Dr. Robert Goldberg
Robert Goldberg, MD, FACOEM, is a board certified occupational medicine specialist and chief medical officer at Healthesystems, a leading PBM and ancillary medical benefits manager serving workers’ compensation payers. A past president of the American College of Occupational and Environmental Medicine, Dr. Goldberg is a nationally recognized authority on occupational medicine and musculoskeletal injuries.
Read the spring 2014 issue of the RxInformer clinical journal or download the app for iPad on the App Store to access an opioid tapering case scenario involving a typical injury seen in workers’ compensation. The issue also contains an article on preventing chronic opioid use. In addition, Dr. Goldberg provides insights on developing pain management strategies to minimize use of opioids in Leaders Speak.
This is a sponsored post from WorkCompWire marketing partner Healthesystems.