There can be equal fear in starting and stopping opioids for pain management. Pharmacist Dr. Julie Cunningham joins the podcast to discuss the process for beginning and tapering opioids responsibly, and how patients and providers can work together to treat pain safely and effectively.
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Read the transcript:
Benjamin Lai: Hello. Welcome to “Ending the Opioid Crisis.” I’m Dr. Benjamin Lai.
Holly Guyer: I’m Dr. Holly Guyer.
Benjamin Lai: This is a podcast series aimed at getting a deeper understanding of the opioid crisis that has ravaged our country. I’d like to welcome you to our podcast, and I’d like to welcome our guest, Dr. Julie Cunningham. Dr. Cunningham is a pharmacist who previously worked for many years at Mayo Clinic’s Pain Rehabilitation Clinic. Julie, welcome to our podcast.
Julie Cunningham: Thank you, Ben. Happy to be here.
Benjamin Lai: Julie, would you like to tell us a little bit about yourself?
Julie Cunningham: As you mentioned, for many years I worked in our chronic pain rehabilitation program as the primary pharmacists, and my role with that team was to help to really de-escalate opioids in that patient population. In addition to that work, I’ve transitioned more into an administrative role where I do a lot of work with our opioid stewardship team and help to really change some of the practices that we see both in our inpatient and outpatient environment.
Benjamin Lai: Julie, it’s great to have you. You’ve spent many years in the Opioid Stewardship Group and also many years in the pain rehabilitation clinic. Julie, what is one of the challenges when you meet a patient in the pain rehab clinic who would like to work on tapering their opioids or lowering their dose? What is your approach?
Julie Cunningham: One of the biggest challenges that patients have is their fear related to what that process is going to look like and that fear can keep them from wanting to move forward with tapering their opioids. Often they may feel that their pain is going to get worse and in fact that they have relied on opioids as their tool to manage pain over the years.
It is really understandable that they think taking away my tool is going to make my pain worse. We work as a team approaching that patient to help them understand that actually coming off of opioids may in fact improve their pain, may improve their functioning, because there are times when people are on opioids for long periods of time, not necessarily even higher doses, but often higher doses where this can cause a phenomenon called Opioid Hyperalgesia, where that opioid medication can cause the pain to worsen in that patient, which may lead to even higher doses or patients’ pain to continue to get worse.
That often leads to their functioning to decrease. Our approach is to really reassure those patients, to trust us in the process, and to take it one day at a time. In my experience, that is often the thing that limits patients, is that they’re thinking down the road: “When I’m off my opioids, I don’t know how I will manage my pain.”
If they can take it more one day at a time and not look at that, “what if” or “what’s going to happen when,” they’re going to be more successful.
Benjamin Lai: Those are really good points. Julie, I’d love to be able to kind of delve into a little bit more in some of what you just said. You mentioned that term “Opioid-induced Hyperalgesia.” Can you maybe just kind of elaborate a little bit on what that means and does that affect everybody who is on opioids?
Julie Cunningham: Opioid-induced Hyperalgesia is also very similar to another phenomenon that patients may hear, which is Central Sensitization Syndrome, and the two are closely linked. When you’re on opioids and you continue opioids for a long period of time, that can actually cause a negative effect within our receptors as we continue to expose patients to opioids, and that may lead to an increase in pain and an increase in opioid requirements to manage pain.
It’s an unfortunate cycle that can occur where opioids, as patients continue to take them, their pain may increase, which may lead to an increased dose, which may cause pain to improve for short periods of time, but then again leads to that increase in pain. That is a little bit of an explanation of how opioids can actually lead to this phenomenon.
Benjamin Lai: That’s very interesting. The longer we’re on it, the more likely we are to have potentially worsening pain. That makes sense for at least some patients to consider tapering their opioids. Now, you mentioned the fear in tapering opioids, Julie. Are there any tools or anything that we should be paying closer attention to, be it for our medical provider community or our patients or their families? What should we monitor as patients start tapering? Should we be careful about watching out for withdrawal symptoms or mood related issues?
Julie Cunningham: We often think about, as we taper, patients can experience withdrawal, but actually, if we’re tapering correctly in a very slow and methodical type of manner, it’s unlikely the patient is going to experience many withdrawal symptoms. Withdrawal symptoms occur when patients really make large jumps and decrease their dose or very quickly taper off of their opioid medications.
While it’s important to identify if withdrawal symptoms occur, in most cases in that outpatient clinic setting, when we’re tapering opioids, we’re rarely going to see withdrawal type of symptoms. However, what we really should be looking for is to keep a pulse on the patient’s mood. Even before we start tapering, it’s important to identify if the patient has untreated depression or anxiety, because we know that in those situations that can actually correlate with unsuccessful tapering.
We want to treat depression, we want to treat anxiety before we actually start a taper, and then keep an eye out for that as the patient is tapering. With that said, we really need to monitor the patients more closely when we’re tapering. If you’re typically seeing a patient in the clinic every few months or every three months when you’re tapering, you may want to have your support staff contacting them every week just to see how things are going.
Or at least the first week after a reduction is made and to identify if concerns exist in those situations. I would say the other thing that we want to make sure we monitor for is the occurrence of opioid use disorder and again, before we start tapering.
But also if a patient is struggling with tapering and we’ve made a small change to their opioid dose and they really experience a kind of uncharacteristic increase in their pain or increase in their distress level, then it’s important to really identify “might this be opioid use disorder?” Use the validated tools to address if this is what is going on with the patient and appropriately refer them or treat that opioid use disorder.
Benjamin Lai: Those are really, really nice points, Julie. Maybe a little bit more in-depth about opioid tapers. How long do they generally last? Do people taper when you say a quick taper versus a slow taper? What’s the variation in the length of time?
Julie Cunningham: The thought on this and the guidance has changed a lot in the last five years. We have new guidelines from the CDC on opioid prescribing and tapering. Just in 2022, in November. Prior to that, the guidelines were from 2016. Then those original guidelines were advocating for tapering by reducing the opioid dose about 10% every week. That amount would be very quick tapering in today’s standard.
Over the last five years, we’ve really seen a reverse in that thought process. The new CDC guidelines recommend anywhere from 5 to 20% reduction every one or two months, especially for those patients who are on higher doses or who have been on opioids for long periods of time. On the flip side, you might have a patient who has been on daily opioids for just a month or maybe a couple of months.
They certainly do not need to be tapered over a year’s time. Those are patients that we could look at tapering by that 5 to 20% every week. To help decrease that dose over the period of about a month or a little more than a month. The other piece with tapering, we want to really make sure that we’re communicating well with our patients, and again, we’re seeing distress.
We’re seeing signs of increased depression or anxiety. It is appropriate to pause, taper. As long as the patient is making progress then this is successful and we should be communicating that to our patients. It’s okay to pause tapers. Often the patients may advocate, though, to go back to their original dose, and providers may be tempted to do that.
But we really want to discourage this. Pauses are probably better to just hold up where they’re at that time and look to support the patient with other means of non-pharmacological or non-opioid pharmacology to help support them in managing their pain or managing other symptoms.
Benjamin Lai: It sounds like close communication and follow up with our patients would be one of the best tools.
Julie Cunningham: Absolutely.
Holly Guyer: In March of 2023, the FDA approved the first over-the-counter naloxone nasal spray to fight the opioid epidemic in the United States. As we continue to navigate the crisis of opioid use, Mayo Clinic is here for you. My book, Ending The Crisis, is a handbook for anyone whose life has been touched by opioid use. Read personal stories of those struggling with addiction.
Hear advice for safer opioid use, and get step by step instructions on how to administer the lifesaving drug naloxone. Visit the link in the notes of this episode or visit mcpress.mayoclinic.org/opioids to get your copy today.
Benjamin Lai: Julie, I’d like to shift gears a little bit. We talked about opioid tapering. I’d like to talk about starting opioids. There are times and circumstances when opioids are needed for treatment of pain. When we start patients on opioids, Julie what are some of the keys that we should look for? Should opioids be used solely for pain control, or should other therapies be added when a patient is on opioids?
Julie Cunningham: When we’re talking about starting opioids, I think about it in two different buckets. You have patients who are starting opioids because they have acute pain, and really opioids, in those cases many times, are ourfirst line therapy and our primary tool. But as you mentioned, in addition to other medications, we call this a multimodal pharmacological plan.
We wouldn’t just use an opioid to manage their pain. We would use an opioid in concert with other medications, such as over-the-counter medications like acetaminophen or Tylenol, non-steroidal anti-inflammatory drugs. Examples here would be your ibuprofen, naproxen, Aleve, that’s a brand name there. We’re using those over the counter medications more as our mainstay, using them around the clock to manage the pain.
The opioid may be more augmentation for when pain gets to be more moderate or severe. That’s kind of your scenario and your acute pain. We’ve really changed our thought process on how we prescribe opioids for acute pain, where it used to be the norm for any procedure or even acute injuries that are mild that wouldn’t necessarily use opioids.
We were prescribing larger amounts for patients across the board without individualizing it, and now we’re much more thoughtful about using a supply of opioids that is appropriate for the type of pain and using that lowest dose to treat the patient. We don’t have to prescribe in even quantities. You don’t have to always prescribe 20 tablets.
We may prescribe three tablets for a patient who has had a procedure that we really wouldn’t expect them to have much pain. But there could be that situation where their pain escalates a little bit to that more severe stage where the other medications that we’re prescribing aren’t fully treating it. Just a comment a little bit on chronic pain because that’s the other bucket. Chronic pain, you may have a patient who has tried a lot of other medications and they really
haven’t been successful. That might be the patient where it’s appropriate to now start an opioid.
But we want to do that in a really thoughtful manner. Again, it’s maybe more of a last resort and the patient is not functioning well, their quality of life is not good. That’s a situation where an opioid may be appropriate to trial, and in those cases, again, we’re starting with the lowest dose and we’re not escalating that dose on a regular basis or quickly. We really want to assess how you are doing with this medication? Are you having significant side effects that may make using the medication more risky than the benefit that you might receive?
Are you achieving some of those goals? Is your functioning better? Is your quality of life better? Even starting it in that setting, we want to very closely communicate with the patient and not just start it and go and not really think about it any longer.
Benjamin Lai: That’s great, Julie. I want to just pick up on one of the points you mentioned there. You had said side effects and potential risks. What are some of the tips that you have for patients and maybe for medical providers as well? What are some of those risks and side effects that we should be looking out for for somebody who’s new to opioids?
Julie Cunningham: Well, there’s the ones that we often think about, and that is they might make us sleepy, they may make us more fatigued, they may make us more clumsy. We want to be really careful about driving when we’re using these medications, and in fact, would not recommend driving at all, especially when they’re new to a patient or operating different types of machinery. That’s kind of a common one.
Another very common one with opioids is that they’re very constipating. In fact, we should be prescribing a laxative along with our opioid medications to ensure that patients don’t actually get into trouble where they might develop a bowel obstruction. Those are a couple common ones that people have. There’s also some things as we think about using opioids longer term that maybe patients and providers aren’t as familiar with, but there can be some different endocrine related side effects.
We can see changes in hormone levels such as testosterone and estrogen, and that also may lead to some of those more long term effects of causing fatigue and decreasing energy in those different situations. Along with those hormones, we also may see change in cortisol levels. Our adrenal system. When you think about your adrenal system, that is your fight or flight type of response.
Patients who are on opioids long term may have a suppressed adrenal system and so they may actually not respond very well to stress, and then when we are stressing them by tapering their opioids in some situations, that can actually cause them more distress than what you might expect. Those are things to think about and potentially monitor on a regular basis as well.
Benjamin Lai: Yeah, very interesting. You know, Julie, sometimes when I prescribe an opioid to somebody, to apatient who’s never been on opioids before, a common question they ask me is: “can I have an alcoholic beverage every now and then?” Or “sometimes I take medicines for sleep like a sedative.” Do you have any thoughts, and what would be your advice to those questions?
Julie Cunningham: Unfortunately we see this in movies where Hollywood shows us an example of people using pain medications and drinking wine at the same time. It’s not uncommon for patients to really think “they did it, it’s probably fine if I do it as well,” or hearing that from friends or family where it’s not an issue. But unfortunately, the more we’re adding on these different agents, which we call central nervous system agents so they can really affect that systemand cause us to be more sedated and suppress our respiratory drive, they can add up.
In those patients who are chronic that use opioids chronically, maybe they’re taking other medications for anxiety or a muscle relaxant or sleep, like you said, they kind of get used to thinking, “well, you know, this is how I respond,” but then they take that one more or have a drink of alcohol with it, and that really can be the thing that causes that respiratory drive to decrease to the point of now we have a real problem and the patient is actually in an overdose type of situation.
We want to be really cautious and I think making sure that we’re accountable to how we take the medications, avoiding those other medications, especially at the same time, but within really intervals of time too if they are necessary, to continue, such as 4 to 6 hours between doses is appropriate, but varies depending on the different types of medications.
We want to avoid alcohol in those situations completely. People who are acutely or chronically taking opioids should avoid alcoholic beverages. Then with the other medications you should really talk to your pharmacist, talk to your provider to understand what is safe with these medications.
Benjamin Lai: Very, very nice, kind of summary there. We’re going to come full circle, Julie. IInitially we talked about discontinuation of opioids and now we’re talking about starting opioids. Say we’ve started a patient on opioids because all of the other therapies have not been adequate, maybe family members or medical providers are concerned about when we should say: “yeah, we may need to stop or start tapering” opioids in a particular patient.
Julie Cunningham: Touched on this a little bit before when I talked about how we want to make sure we’re meeting goals. We want to make sure that the patient is achieving goals with their functioning and that their quality of life is improved with this medication. As we’re evaluating whether the benefit of being on the medication is greater than the risk, you’re thinking about those different things that’s functioning and quality of life.
If you’re actually seeing some of the risks and concerns from family members or patients really outweigh those, those are conversations to have with the patients to really develop a shared decision making model to begin to decrease those opioids. As you look at other ways to manage that pain differently.
That is extremely, extremely important as we consider being on opioids long term. It may change over time too, as we age, as other medications are added into the mix, as other potential chronic diseases may develop, then that medication that you were on and maybe was achieving some of those goals, may no longer achieve those goals. As we mentioned before too the Opioid-induced Hyperalgesia. That may be something that results in being on the medication and increases the risk or decreases the benefit to the patient.
Those are the things that I really need to have those conversations with. It often may be a family member that is bringing up that concern where the patient feels like: “I don’t think that’s a problem. I think I’m doing fine on the medication.” So it’s good to really reflect, ask those questions and to again in that shared decision making model, move forward with plans to make changes and in those cases decrease the opioids.
Benjamin Lai: Thank you, Julie. One final question for you. There is more press now and more attention on Naloxone or Narcan. When should that be prescribed? Do you have any tips on how to counsel patients or their families on Naloxone?
Julie Cunningham: I advocate for a very low threshold for prescribing Naloxone, certainly patients who are chronically on opioids. I don’t even think there’s the dose that they’re on that’s too low to consider or to have those conversations. Having access to Naloxone is important for the patient. But also what if you have the medication and a family member were to get into that medication and then having access to the Naloxone could be lifesaving in that situation as well?
Usually what we see in the literature is thinking about prescribing Naloxone in those higher risk situations, though, so high risk situations, maybe higher doses of opioids that the patient’s on and that could be even 50 morphine milligram equivalents are higher or some people may have a little bit higher threshold. Certainly if the patient also is on those other sedating medications or central nervous system acting medications like the anxiety medications or sleep medication that increases their risk and having Naloxone available would be important for those patients.
Other situations may even be when you’re tapering. People think, well, I’m coming off my opioid and so my risk is lower. I shouldn’t need Naloxone now. But in fact they may be tempted to take higher doses on days that they’re struggling on. As we lose tolerance to that opioid medication, that may put them in a risky situation where Naloxone could be life saving as well.
The product of Naloxone that is most often prescribed, and most insurance plans cover this, is the nasal spray. It’s super easy to use. It’s just a product where you’re spraying a puff into the patient’s nostril. When you identify that their breathing has decreased, you may see a blue color, you may not be able to arouse them.
First thing you would actually do before even administering Naloxone would be to call 911. You want to get emergency services on the way, but then to deliver that dose of the medication. Then usually those kits have at least two doses and that may be enough to revive patients. But we do know, especially with illicit drug use, where the drug supply has fentanyl in it, additional doses may be needed as well, or the patient may lapse back into that overdose state and need additional. That’s why it’s really essential to call 911 at first.
Then we do note too, after administering Naloxone, that sometimes the patients can lash out and become a little bit violent as they’re disoriented in more of an aggravated state. It’s important to kind of give the patient some room after administering that medication, but very easy to use and again, low threshold for a patient asking for it or providers prescribing it for their patients.
Most states have laws that allow for the outpatient pharmacist to be able to supply that to the patients. We actually may see Naloxone moving to an over-the-counter status here soon in 2023.
Benjamin Lai: That is great to know, Julie. Julie, it’s been so wonderful talking to you. You are just a great source of expertise and knowledge. We thank you so much for your time. That is all from us on today’s episode of “Ending the Opioid Crisis.” You can check at our website at mcpress.mayoclinic.org/opioids for more episodes of our podcast series and other resources for safe opioid use.
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