Go Slow When Tapering Patients on High Dose Opioids

The College’s Council recently endorsed the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain as evidence of best practice.

Among the many recommendations, the guidelines identify that opioids are not a first line choice for chronic non-cancer pain. When opioids are indicated, an upper limit of 90 morphine equivalents per day is strongly recommended.

As you incorporate these new guidelines into your practice, I would ask you pay particular attention to the management of your patients already maintained on doses of opioids in excess of 90 morphine equivalents per day. In keeping with the recommendations, these patients should be offered drug tapering.

These can be very difficult conversations to have with your patients. Discussions about tapering must be done sensitively, collaboratively, and with realistic expectations.

When tapering opioid medications, physicians should be aware of the following:

• go slow when attempting to taper opioid medications and care must be taken when attempting to taper these medications;
• be aware of the associated harms and risks to your patients;
• withdrawal can be dangerous and rapid decreases in daily doses or sudden discontinuation is never acceptable;
• monitor and evaluate medication and discuss with your patient impacts of reductions; and
• do not abandon patients on high doses.

While the guidelines recommend offering multidisciplinary support to those who experience challenges, the College recognizes such support services are not yet available in many communities in the province. Addressing these gaps has been identified in the development of the province’s opioid response plan.

Yours,

D.A. Gus Grant, AB, LLB, MD, CCFP, ICD.D
Registrar and CEO
College of Physicians and Surgeons of Nova Scotia