Before tapering patients treated for cancer off of opioids, care providers should first establish what the goals of tapering are.
During opioid tapering in patients treated for cancer, education is critical, explained Taylor W. Butler, PharmD, BCOP, BCPS, during a session at the 2023 HOPA Annual Conference. Butler said that focusing on guiding patients through the tapering process makes the transition easier to facilitate due to the established trust.
Butler explained further that he has found it to be valuable to understand the history of practice on a certain area to better understand the practice today.
“For example, I feel like you can appreciate a mastectomy and a lumpectomy more if you know where we came from with the radical mastectomy. So I tried to do that with opioid tapers as well,” Butler said. “Really early on, any data that was published about opioid tapering really focused on patients who had opioid use disorder (OUD) and how to get them off these medications successfully. In 1984, there was a study that talked about acute pain, and in 1986, there was a study about chronic pain. But then after that, there was essentially nothing that focused on chronic opioid therapy until about 2013.”
During that time period, Butler explained that there were more data available on buprenorphine and methadone tapers for OUD; however, there were no data analysis on chronic non-cancer pain.
“In that time period, we know that the opioid crisis happened. So people started to get interested again, and let's see if we can get these patients off these medications. So in 2013, the legs are starting to ramp up again for opioid tapering. And then finally, another big time point, we'll kind of talk about why this big time point was in 2016, the CDC actually released guidelines about chronic opioid therapy,” Butler said.
Butler noted that a large portion of the guidelines were about opioid tapering. He said that it is important to first establish what the goals of tapering are.
“Why do we want to do this to our patients? You're going to have a patient sitting in front of you, who says, ‘Oh, I have pain, I need this medication.’ So why don't we want to offer to lower these medications. And so, our first goal is that we want to improve or keep their pain and their function the same. So, our goal is we're going to lower their doses, their pain is going to get better, their function may get better, or at least that it'll stay the same, and they'll be on lower doses.”
The next goal is to find the lowest effective dose, which Butler said is important to establish because although the intent is to get patients off opioids completely, that doesn't happen for every patient. He noted that is okay and care providers should seek to find the most effective dose. After that dose is established, the next goal is to reduce long-term opioid toxicities.
Butler said that along with mitigating the risks of long-term opioid use, decreasing costs for patients is also important, including costs for urine screening and drug testing, which can add up and be very prohibitive to patients.
Butler said that ultimately, the goal is to minimize withdrawal symptoms.
“You have a patient coming in to you and they're stable, there's no need to rush them and increase the risk of withdrawal symptoms when they're doing okay,” Butler said.
Butler TW. Considerations in Opioid Tapering in Cancer Survivors. Presented at HOPA Annual Meeting 2023 in Phoenix, AZ.