Hi, my name is Erin Krebs and I'm a general internist and a researcher and I'm at the Minneapolis VA and the University of Minnesota here today to present another presentation in the PCSSO training series on opioid therapies. Today I'm going to talk about keys to communication success in opioid management. And the objectives of this presentation are to recognize patient perspectives on pain in opioid management, identify practical approaches to limiting, reducing, or discontinuing opioids while maintaining a good relationship with patients, and describe the role of shared decision-making in opioid tapering and discontinuation. So I'm going to start today with a perspective piece by Dr. Mitchell Katz that was published a few years ago in Archives of Internal Medicine. And I think this piece really illustrates very well the sense of conflict that many physicians feel when managing opioid therapy. He starts out by saying, as a patient-centered internist, I've never wanted a patient of mine to suffer needless pain. During my residency in the 1980s, I was influenced by studies showing that physicians undertreated pain and I vowed that I would not practice in this way. And then he goes on to talk about his practice and how he used opioids to treat chronic pain in a number of his patients, and how eventually he ended up in the situation he describes in this way. Before you know it, the patient is on a high dose of an opioid and you are unsure whether you've actually helped them. What you know is you've committed yourself to endless negotiations about increasing doses, lost pill bottles, calls from emergency departments, worries your patient is selling the drugs, and the possibility that one day your patient will take too many pills, perhaps with alcohol, and overdose. And I'm sure many of you can identify with this kind of scenario. The goal of this presentation is really to make the case that it is possible to be both patient-centered, holding on to those original ideals, and also avoid the trap that Dr. Katz describes here. So patient-centered opioid management, just to start with the definition, in my view this is a commitment to respecting patient preferences, needs, and values, but it is definitely not a commitment to continuing potentially harmful or ineffective therapy. So what I'm going to talk about first is some supporting evidence in terms of opioid taper outcomes and patient perspectives on opioid tapering and discontinuing of opioids, and then to talk about some practical advice for how to implement this in clinical practice. As far as opioid taper outcomes go, a few years ago I would have told you there was almost no evidence on this topic. The good news is that we do have increasing evidence with ongoing research in this area. And so now we can say that there is some evidence. The bad news is it's overall low-quality evidence on patient outcomes of opioid dose reduction. The reason that the body of evidence has been rated low-quality is due to both small numbers of studies, small numbers of patients in the studies, and in some cases, lower-quality study methods. A couple of types of studies are worth highlighting. First, a number of observational studies of opioid tapering in the context of intensive multimodal pain programs have been published. And in general, these show improvements in pain and function, along with tapering in the programs. Second, studies of opioid tapering that involve lower-intensity support, both clinical trials and observational studies, generally show improved or unchanged pain and function. The evidence on adverse effects of opioid reduction is even lower quality at this time. That's been rated in systematic review as very low-quality evidence. Really, this is mostly due to limited reporting. We do have anecdotal reports that make us concerned that abrupt discontinuation may be associated with serious harm, such as overdose and suicide. So abrupt opioid discontinuation is not recommended unless there's a really strong clinical rationale of risks outweighing or benefits outweighing risks of that approach. Another source of evidence really is the patient perspective on this. And this has been a relatively under-researched area, but we do have some evidence. In particular, we know that, at least from some survey data, many patients are ambivalent about opioids or describe wanting to reduce their opioid doses. So one survey published in 2012 that was conducted among health plan enrollees receiving opioids found that 43% of them reported wanting to stop or cut down on their opioids. And those are those patients who actually rated opioids as at least moderately helpful. So really, this is ambivalence. They think they're helpful, but they want to stop or cut down at the same time. And this table kind of illustrates potential reasons for that ambivalence. So the columns here are, on the left, the problems or concerns that the patients reported. And then the middle column there is those who reported they had a desire to stop or cut down. And then on the right, those patients who had no desire to stop or cut down on opioids. And you can see that there's a difference in the two groups of patients in terms of their experiences and concerns. So patients who want to cut down are much more worried about dependence on opioids, about bothersome side effects. They report that they need a higher dose for the same effect, more likely to report feeling less ill or it was driving, et cetera. So you can imagine why you might feel ambivalent if you thought the pain medication was helping, but also causing harm. Theory of research is another source of findings on patient perspectives. And on the next few slides, I'll summarize findings from a series of studies that I've participated in that have used in-depth interviews with patients and physicians and observations of clinic visits to understand how patients receiving long-term opioid therapy feel about it, their perspectives on it, and the communication among patients and physicians on the topic. So in this series of studies, two of the strongest themes we found were that patients receiving opioids really wanted to be treating as individuals. So it was very important to them that they be treated as a whole individual human and be seen in their complexity. And what they really feared was being stereotyped as drug seekers or fakers. So the concern is that they were grouped in with a whole bunch of people who were faking pain or seeking drugs, and they really wanted to be treated individually. The second theme that was really prominent was that patients want doctors to listen and understand their pain. And that goes beyond pain as a number in terms of intensity. The quotes on the following slides are from interviews with patients in these studies. And all of these patients were receiving long-term opioids for chronic pain. So this quote, this is from a patient. This is nothing against my doctor, but 99% of the conversations we ever have, because it's only every six months or a year, is my physical weight, blood pressures, what number of pain I'm in. But there is no conversation about pain. In my personal belief, and my doctor is the best I've seen over these four decades, is that they're at a loss at this. So here's a patient who really perceives that we don't know what to say, we're not sure what to do, and that is part of the reason that we don't ask about pain or want to hear about it. So other findings from this series of studies were that patients commonly express concerns about opioid dependence and addiction. And I'm talking about those separately. Sometimes we think about physical dependence as being sort of benign, but many patients fear physical dependence just as they may fear addiction. They don't want to have to take a medication every day. They don't want to be chained to that. The other thing we found is that patients really expected doctors to monitor safety. They felt that this is our job to help protect them against harms of the medications we prescribe. So as one patient said, I think any patient should have some say, but it's the doctor's responsibility not to let you become addicted. And really for me, it's my responsibility too. Some people don't look at it that way. They just, I don't know, just pop pills. So this is a patient who sees that some patients maybe are too passive and are allowing doctors to put them on a high-risk medication they may be harmed by. We also found that very commonly patients described high expectations for opioids that conflicted with their own experience. So they thought that opioids were highly effective drugs, you know, powerful painkillers, but at the same time described really having poor results of opioid treatment. And quite a few of these people really couldn't describe much benefit of opioids, but were taking them despite the lack of benefit. So in the interviews, patients really differed in how they described their response to this gap between expectations and personal results with opioids. Some deferred to their doctor's judgment. So this is a patient who was taking his medication as recommended, even though it didn't seem to help. I would really expect them to get rid of all the pain there is, but maybe my expectations are just more than what it can do. I just trust my doctor is all. And this is another patient, more skeptical. He thought that his doctor was really holding out on him, and that he just needed a higher dose. That's why the medications weren't working. I tried to explain that they're not really working for my pain. I mean, my body's probably gotten used to them, and I get from her there's nothing else she can give me. This patient also is taking meds that aren't working. A final finding that was very interesting is that patients interpreted limitations on opioids, and I mean limitations set by their prescribers. Really they interpreted those in the context of the relationship with that prescriber. So if there was a good relationship and they felt their doctor cared about them, they often would attribute the limit set by their doctor to concern for their well-being. So kind of almost positive kind of paternalistic outlook. This is an example of that, a patient who had his hydrocodone dose reduced after going to the emergency room for opioids. I was a little upset at first, but I kind of understood what he did, because I have been coming into the emergency room for other issues, and the other doctors were giving me stuff, and they weren't notifying him. I don't feel it as a punishment. He just wanted to make sure I wasn't getting overindulged in what I was using. So I was glad he did what he did. Got to keep me in check sometimes. So in summary, we have limited research on processes or outcomes of opioid dose reduction. We do know that many patients have concern about opioids, fail to receive the expected benefit from opioids, or desire to reduce use. So this is really an opportunity for us to introduce the idea of opioid dose reduction. And qualitative research supports the importance of a patient-centered approach to opioid therapy, really focusing on treating the patient as an individual and listening and expressing empathy related to the effects of both pain and opioid therapy on the person's life. Okay. So having talked about supporting evidence, and in many ways we are rather in an evidence-free zone in terms of processes and outcomes of opioid dose reduction, I'm going to move to talking about some practical advice to really how to get this done given what we know. So these are three steps as I see them to patient-centered opioid reduction. So first is that individual care thing. We want to develop an individualized benefit and harm assessment for our patients in front of us based on what we know from the evidence about opioid benefits and harms and about the individual patients and their values. Second, we want to share decision-making about opioid dose reduction options when we can. And I'll talk a little bit about that. In some scenarios you can share more than in other scenarios. And third, implementing a taper trial. And I frame this as a trial to leave a little open-endedness to it. So this is how I talk to patients. I recommend tapering. I don't necessarily always know the final goal in terms of the final dose or whether we're going to completely discontinue the medication. But what we're really aiming for is the improvements in either the quality of life and reducing the risk of harms or the side effects, whatever the patient-centered goal of the trial is. So starting on talking about developing an individual benefit and harm assessment, it's key that really what we're doing here is judging the therapy, not the patient. So questions we are not asking, is this a good patient, do they deserve opioids, should they be punished or not, should I trust them? But really, the question is always, do the benefits of this treatment clearly outweigh the harms and the risk of future harm? Assessing benefits and harms is actually a very difficult thing to do. I'm sharing on this slide a flowchart that was published in a really valuable document, the HHS Guide for Clinicians on Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. And as you can see, they really include a lot of different variables in this assessment. So this is, you know, I don't have a live audience for this webinar, but I am going to ask you to just pretend that I'm polling you. And I'm going to ask you to just take a moment to think of the last patient for whom you wrote an opioid renewal prescription. Just get a picture in your head of this person, and really this should be someone on long-term opioid therapy. Now once you have them in your mind and you're thinking of that prescription you wrote or typed in, how confident are you that that particular patient is experiencing substantial benefit from opioid therapy that is clearly outweighing any harms they're currently experiencing or any risk of serious future harms? Now when I do this for a live audience, I will say that I have very few people who say highly confident. And those who raise their hands to that are often, maybe they're practicing failure of care. But for those of us in primary care, usually prescribing long-term opioids for chronic musculoskeletal pain, what I get is a smattering of somewhat confident and also not at all confident. That's where most of the votes come in. So I think in terms of assessing the individual benefit of opioid therapy, that we really need to acknowledge how hard it is, but also how truly important it is. Because in the absence of demonstrable benefit, I really say that no risk of harm is acceptable. Someone may be low risk for a fatal outcome of opioid therapy, but if they're not benefiting, how could that possibly be an acceptable risk-benefit ratio for them? Really, determining the presence of benefit is critically important. And as I mentioned earlier from those qualitative studies, it is clear that patients do continue to take opioids every day, even those patients who are not experiencing benefit and those patients whose pain may be worse on opioids than off opioids. This is really a counterintuitive to people, especially non-clinicians, I think, have a hard time understanding that someone would take a medication every day for a symptomatic condition and not get benefit but still take it. And I think it's clear that this happens and there are many reasons. I gave you the quote earlier about the very compliant patient who is simply following his doctor's advice. That may be less common. I think a common factor is that many patients fear they would be worse off without it. So they feel terrible today. And since they believe very strongly that these are highly effective medications, they're sure they would be even worse if they didn't have them. I also gave you a quote from a patient who thought that all he needed was a higher dose or a stronger medication, even though he was already on a high dose of opioids. This is a very common belief. These medications must work. And I think here it's just important to mention some of the data we have that I'm not going over in this talk but that other talks do, just that opioid therapy is not effective for the majority of patients in the long term. And even in really what we have is short-term trials and in those trials, a small minority of patients get a good response. And the majority of patients don't get a reasonable response. So we should probably be setting the expectations lower. Another really important factor is the role of tolerance and dependence. So patients who have physical dependence to opioid therapy may have experienced worsened pain or withdrawal symptoms, feeling ill between doses when they miss a dose, if they run out of their drugs. And that can be very reinforcing in terms of the belief that the medicine is helping the pain and that they do need it. So those are some of the reasons patients continue opioids without benefit. So how do you assess benefit? You know, I think it's really important to focus this conversation on what the patient's life is like, asking about things like activities and limitations. So tell me about a typical day for you. Tell me about yesterday, when you got up in the morning, what was your day like? And just have them tell you what they're doing. Ask for some perspective, you know, compared to five years ago, how is your life now? How would you like your life to be in five years? Are there things that are important to you that you don't do anymore because of pain? You know, what would your life look like if you weren't limited by pain? And then when patients tell you that their opioids are helping, or they're helping a little, or they're taking the edge off, really trying to get them to be specific about what opioid effects they are experiencing. Tell me exactly about how it's working. How do you know it's helping? Tell me how that feels. What do you mean when you say it helps? You know, sometimes patients can admit when you start going down through these pathways of conversation that actually they're not really sure. And then you have some common ground to move forward with. So in terms of the benefit-harm assessment, assessing harm is actually probably much more straightforward. But there are some important things to think about. So first, you know, the categories of harm that we should be assessing. I kind of grouped those into three categories. First, adverse symptoms or side effects. Second, risk factors for major harm. And when I say major harm, I'm talking the catastrophic stuff, the overdose, the severe injury, car crash, addiction, those kinds of things. And then evaluating for evidence of problematic opioid use or misuse. And I think we probably emphasize this last one too much when we talk about evaluating harms of opioid therapy. I really think of evidence of problematic opioid use or opioid misuse. Those are really kind of risk factors for major harm in and of themselves. They're sort of signs that something is going wrong or that the patient is at high risk for a future problem. And then, you know, it's always important to note, especially when we're trying to have a patient-centered conversation, that the most salient harms for patients are often different than the most salient harms for prescribers. So we as prescribers tend to think about overdose, death, addiction. And often patients are not as concerned about those things as we are, or perhaps they're concerned but believe they're low risk. So a patient may know, for example, that they take the medication just as you've prescribed it, three times a day, you know, at the right times, that they don't drink, that they don't use other drugs, and they may believe that that makes them very low risk for addiction or for experiencing opioid toxicity and respiratory depression. And those beliefs may be hard to dislodge, even if we're not so confident. They may be much more concerned about day-to-day symptoms and side effects. So I think where it's sometimes easiest to make common ground in terms of talking about harms of opioids is on adverse symptoms. And so this is something that, you know, you can really talk with your patient about. You know them, you know what's going on. Could opioids be causing or contributing to bothersome symptoms, and actually be decreasing their overall quality of life? And listed on this slide are just some of the really common bothersome symptoms that patients who are on opioids are concerned about or complain of. Probably the biggest one of all is really the cognitive adverse effects. Poor concentration, focus, memory, fatigue, poor motivation, anhedonia, depressed mood. I mean, these are very common with opioid therapy. Sometimes they get attributed to the pain, but it may be that the opioids are actually making these problems worse. We sometimes poo-poo things like constipation, but GI adverse effects can be very important to patients and really affect their quality of life. You know, and other things like, you know, are they having daily headaches? Could there be an analgesic overuse syndrome? Other things you should explore. And really importantly, going back to those questions about what people are doing with their days and what they would like to be doing if they didn't have pain, how could opioids possibly be interfering with their life goals? I think these are conversations that can really help us get on the same page with patients. Okay, so talking about risk factors for major harms. This is really just a very simplified table trying to summarize on the left hand some of the major risk factors that have been found to be associated with serious harms of opioid use, overdose, or, you know, I think sometimes we should be calling this opioid toxicity because I don't think you have to take more pills than prescribed to experience respiratory depression and death from opioids, trauma, and opioid use disorder or addiction. At the top of the list on the left, you know, higher doses are clearly associated with all these major harms. And so are concurrent sedative hypnotic drugs. And these things are fully within our control. These are treatment factors that are among the strongest risk factors for major harms among patients on long-term opioids and things that we can address. The other issues, history of substance use disorder, mental health conditions, tobacco use, having severe pain, younger age, family history. Some of these things are modifiable or not, but really I think it is important to focus on the risk factors that are within our control. And then finally, we do need to assess evidence for opioid misuse or problematic opioid use. I think of these as non-adherence behaviors, and I think the best way to evaluate for them are looking for objective data and signs of problems. And that objective data really is gonna come from things like drug testing with urine samples, which I think should be done absolutely for everyone, regardless of risk, on a regular basis. Checking your state prescription monitoring program database. Most of the time, those checks will turn up nothing of concern, but they provide really actionable, important information. So also, something that should be routinely done with our patients. And then medical record review. It is really, especially with electronic records, possible to learn a lot just from seeing some of the other visits that our patients have had and get a sense for some of the patterns and problems. I do think it's always important to consider a differential diagnosis for any behaviors that are observed or identified. And the differential diagnosis tends to be broad, but some of the common things, we always think about substance use disorder or opioid use disorder, true. Could be other substance use disorders, other than opioids. Could be a mood disorder, personality disorder. Could be simply dysfunctional pain coping, feeling desperately in need of relief and taking more drugs than prescribed. Could be opioid-induced behaviors related to physical dependence or tolerance, like I mentioned before. And could just be simply social chaos, which is often common in primary care settings. It's important to try to identify the cause so it can be addressed. It's also important to really recognize that all of these causes suggest an increased risk for opioid-related harm. So these things really do change that risk-benefit calculation, in my view, because they all are markers that the patient is more likely to experience a very bad outcome of opioid therapy. All right, so to just illustrate this exercise of assessing benefits and harms, I'm going to present a case of a transfer patient. It's a little bit of a compilation, but it's from my own clinical practice. And illustrates how difficult this can sometimes be. So she's a 40-year-old woman, and she has chronic low back pain, which has been a problem for many, many years. She has obesity, diabetes, major depression, and tobacco use disorder, or the comorbidities. And she's establishing new primary care with you because her fire physician has retired. Her main concern for the day is that she needs her medications. She has only a week left of her morphine, hydrocodone, and zolpidem. She's been taking morphine SR, sustained release, 33 times a day. So that's 90 morphine equivalents. And then hydrocodone and acetaminophen. It's written as needed, but in reality, she takes eight tablets a day. So at five milligrams each, that's 40 morphine equivalents. So 130 morphine equivalents per day. And then she's also taking zolpidem 10 milligrams at bedtime for sleep. And like I said, she wants to establish care. She needs her medicines. That's why she's here today. So of course, you take an excellent social history. You ask all those questions about how well opioids might be working, and about how her pain is affecting her life. And then of course, I have a couple of questions. I always ask a new patient that I find to be very informative. I always ask, who are the most important people in your life, and what do you do for fun? So from asking these questions, what you learn is she's not working. She's receiving disability payments related to her back pain. She's a single parent of two, really has a lot of financial stress. Being involved in her kids' lives is very important to her, but she just isn't able to do it like she used to be able to. And a specific example is she can't attend their soccer games anymore. She can't walk to the park where the games are held. She can't stand on the sidelines for the course of the game. It's just too much for her to do that. In terms of what does she do for fun? Well, she's pretty isolated. She doesn't really have good friends anymore. People kind of got tired of hearing about her pain. She doesn't do much. She has a lot of TV programs she watches during the day. Really spends most of her time in her apartment, and much of it watching TV or taking care of basic necessities of life. She says she needs her opioids, and they take the edge off. Nothing else is seen to help her. She reports no alcohol or drug use, and she uses her opioids as prescribed consistently. She's very concerned about making sure she takes them carefully because she recognizes the potential harm. From this discussion, you can make an assessment that this is somebody with kind of a chronic, nonspecific, low back pain. She's reporting severe pain, severe functional limitations related to pain, and also she's very physically deconditioned from her description of what she can do. She can't stand for an hour. She can't walk two blocks. From this conversation, I think the benefit of opioids is pretty unclear. If there's any benefit at all, it's hard to say what it would be. You can say that she has very poor occupational, social, and physical function. She doesn't feel that she's meeting the roles. She's not really achieving what she'd like to be in life or meeting her own expectations for herself as a mother. And she has ineffective pain self-management. So really, she doesn't have much she can do for pain other than taking the medications. She feels that's the only thing that's helped her. She does have major risk factors for harms, including her high opioid dose, the concurrent zolpidem, which although it is not a benzodiazepine, likely does have a role in increasing risk of major harms. Her concurrent depression and her tobacco use disorder, all these things are associated with higher risk of major harms. So a plan at the end of the visit is to discuss this assessment with her. So make sure that she understands your assessment. And to talk about safety monitoring and your approach to managing opioids prior to giving her that first prescription she's asking for. And then to schedule short-term follow-up to address really this plan on a long-term basis. Not gonna get this all done in one new patient visit. So if we're talking about discussing the assessment with her, what do we say? These are some of the things I like to say when I'm discussing risk for harms. And I just think it's very helpful to have a spiel that is your usual thing you say. I say we've learned a lot about opioid therapy. And we used to think that the dose really didn't matter as long as we went up slowly on the dose. But now we know that people taking higher doses are at much higher risk for serious injuries and accidental death. So I'm concerned about the fact that you're on such a high dose of opioids today. I also tell people that these drugs can cause addiction in people with pain, even if they've not had problems with drugs or alcohol in the past, and even if they don't misuse their medication. And then in her case, I would let her know that the research indicates that her risk of a serious problem like an accidental death is higher than average because of her dose, her zolpidem, and also because of her tobacco use and depression. That people with those problems are more likely to have a serious adverse event of medication. And then I tell people that I use a standard safety monitoring practice for all my patients. Because these drugs don't discriminate and can harm anyone, I monitor them very closely. And I say, I will be honest with you if you have any concerns about how you are using your medications. If it sounds like you're using them as prescribed, which is great, please let me know if you have any concerns about how the drugs are affecting you. If you notice that you're drowsy, feeling inattentive, concerned about whether you might be developing dependence, please let me know and we'll deal with that. I also say, it's my practice not to prescribe these drugs on the first visit with someone until I get some more information back. I do this with everyone. What I'll ask you to do is have your prior doctor transfer your records to my office. I'll have you give me a urine sample today to do drug testing. Then I'm going to check the state database. This is what I do for everyone as part of my safety monitoring. I'll get that done in the next couple of days. Then we'll get the prescription for you before you run out. Now that we've covered the individual benefit-harm assessment, I'm moving to step two, which is sharing decision-making. You talk about shared decision-making in opioid therapy, and that raises a lot of concerns for many physicians and other prescribers. I think it's important to note that, yes, shared decision-making does involve patient and physician sharing information, expressing preferences, but it does not require the physician or other prescriber to give up the decision authority. Clearly, some decisions are more easily shared than others. What decisions can we share when we're talking about opioid discontinuation or tapering? These are some examples. I think even when we're not making the tapering optional, we can certainly discuss which medication to reduce first, how rapidly to taper, when the taper should start, when to schedule follow-up. Then we definitely have to share decisions about what the goals are in terms of patient's pain management and self-management. That's a good way to incorporate those patient values. What do you want to see get better in your life? The degree of sharing really depends on the urgency of the safety issues involved. This is just a little graphic that I've adapted from a prior publication. It illustrates that although some decisions are shared equally in the middle of the arrow, some are really not shared at all. Many decisions about stopping opioids are made by patients without involving physicians. Actually, this is probably the majority. These are the patients who do not tolerate opioids. We often forget that most patients started on opioids self-discontinued. If they experience severe side effects such as nausea and constipation, many patients will just not take it again. Then you'll see them back months later and they'll say, oh yeah, I'm not taking that. It made me feel terrible. What we're really talking more about today are those decisions that could be more equally shared or need to be driven by the doctor. A decision that is probably a little more doctor-driven but more equally shared would be a decision for a patient who really does not have clear benefit but is on a low-risk regimen without serious risk for major harm. It goes a little bit more down the doctor-directed pathway if we have no clear benefit and a high-risk regimen like the patient I presented to you. It really does mostly become a doctor or prescriber-driven decision if you have a very high-risk situation such as, for example, a urine drug test positive for cocaine and negative for the prescribed opioid. That suggests a substance use disorder or possibly diversion of the prescribed medication. In that scenario, clearly the prescriber is going to be directing the decision-making. Sometimes there still can be some sharing, however. I'm going to go back to those more shared decisions. This slide really applies to someone like the patient I presented that has a situation where benefits of opioid therapy do not outweigh harm. Either you're not seeing much benefit, they're having a lot of side effects or risk for harm, but there's no emergency situation, no exceptionally high-risk immediate problem. Here you want to make a recommendation tied to the patient's well-being. For example, I do not believe that these medications are helping you much at all. Furthermore, I think they're really putting you at risk for serious problems such as accidental death or injury. I think it's time to make a change to your medication regimen. I don't want to continue this high dose. It's important when you make such a recommendation that you really empathize with the patient's situation, both with the effect of pain on her life and all the different domains that affect, and the disappointment and frustration that the medications are not working as they had been expected to work. When having these conversations, it can really help to focus on function and life goals and repeatedly redirect the conversation back to those things because it's very clear that the approach to getting someone's life back really differs from the approach focused on simple pain relief or cure of the underlying pain condition. In most cases, there's no cure forthcoming, and pain relief has not been easily achieved. The focus has to be on getting one's life back and improving function, achieving goals. Then important, of course, to show commitment to caring for the patient. That may be operationalized by scheduling close follow-up and just expressed by, you know, I'm going to work with you. We're going to stick together. We're going to figure this out together. It's a special situation, of course, if opioid use disorder seems likely. The case I presented is someone in whom opioid use disorder is not likely, but often it is the case that we suspect there may be an opioid use problem or we're quite certain that that's what's going on. Here it is important to give specific and timely feedback in terms of the behavior and why you're concerned. I'm worried about your health because you're going through these medications more quickly than you should, and I am concerned you might have lost control of the medications. I'm concerned that you could be developing an addiction. Make sure you blame the drug and not the patient. For example, saying something like, I can't continue prescribing this for you because I think it's hurting you more than it's helping. You know, these are drugs that cause problems for people, and people are not seeking to become addicted to the drugs. It's important to state your plan, and if there are any options, provide those clearly. For example, if there's a situation where there are concerning symptoms or signs, but it's not really clear that there's an addiction or an opioid use disorder, you may be able to taper the patient in clinic and just watch them very closely and see what emerges. If it's quite clear that an opioid use disorder or addiction is present, or if it emerges during the taper, we need to make sure that they have the ability to get to addiction treatment. Whether we're offering a referral or able to provide the treatment ourselves, we need to make sure that we are doing that and we are not abandoning the patient. I'm also very careful to tell people that I really am looking forward to working with them on helping them with their pain through other mechanisms beyond opioids. Going back to our case and now using her to illustrate shared decision-making, this is our 40-year-old woman with back pain and high-dose opioids. We do not think she is experiencing substantial benefit in terms of pain or function. She's back in clinic for her second visit and no change. You did that chart review, looked at the prescription monitoring program and got a urine drug test, and they're all fine. There's really no evidence that she's misusing her opioids. She's just on a high-risk regimen without evidence of benefit. In this case, since we have no clear benefit, a high-risk regimen, and no evidence of nonadherence, this can really be kind of in the middle there. It's a doctor-led decision with substantial patient input because there's no short-term crisis. You make the recommendation, I want to start making some changes to improve the safety of your medication. And then you talk about how to do that. You know, we have options here. There are a variety of ways we could improve the safety of your regimen. We could start decreasing the dose of morphine, of hydrocodone, or of zolpidem, and then, depending on what she decides, how fast do you feel comfortable going? We know from the literature that probably an opioid dose reduction of about 50% every week or so is not going to cause withdrawal symptoms, but for a lot of people, going much slower than that. So, you know, do you want to go down each week, each month? Should we go down one pill at a time? These are really decisions that you can talk through with the patient, and that will give them a sense of some control over the situation that may make it easier to deal with the fact that you're really not giving them an option of whether or not to reduce the dose. Okay, so finally, implementing a TAFER trial. First, again, this is an area for shared decision-making. You have to discuss the goals. Why are we doing this, and how and when will we know if it's worked? Sometimes you may be targeting a specific dose, and sometimes the goal may just be simply to reduce from where you're at. It very much can depend. I will usually start by saying, I think I'd like to get your dose to about half of where it is and then check and see where we're at. My goal would be that they're not having a substantial worsening in their pain or function. This is a victory because if you don't have more pain and you're on a lower dose with lower risk, overall that's better, and most people could agree. They don't want to sign up if they're going to have a lot worse pain. I try to be very clear that pain can get worse at first, and of course we all know that the natural history of chronic pain is that there are flares and exacerbations and fluctuations, and so you don't want to overinterpret those as failure of the tapering. It's important to discuss potential symptoms as the dose are coming down. I almost always go very slow, and that rarely ever causes any withdrawal symptoms, but it's important to talk about that, especially I always talk about how pain might temporarily increase and how sleep might temporarily get worse because if you don't know to anticipate that, you might think the plan is failing. Talk about how to contact in case there are any unexpected issues, and I usually schedule short-term follow-up. I really try to let the patient have a lot of control over when that might be, depending on how nervous they are about this plan. And then I think it's important to identify at least one self-management goal. This is something to focus on other than the pain intensity and other than on the opioid dose reduction. So while we're coming down on your opioids, how are we going to start working on achieving your long-term goals, getting your life back, getting you moving again, really this can help you in your future conversations refocus on those things that are within the patient's control that are about activating pain self-management. So what to say in terms of discussing expectations. You may have temporarily increased pain or other withdrawal symptoms after dose reduction. This is just your body trying to adjust to not having as much medication on board, your brain trying to learn how to interpret those nerve signals. As long as we go slow, I don't expect any overall change in your level of pain. I don't think you're going to feel worse off these drugs. I think you might feel more alert, more clear, more energetic on a lower dose, but that usually does take some time. So you don't want to be too quick to judge this outcome. And then in terms of developing a self-management goal, you said you wanted to be able to go to your kids' soccer games. What would be a good first step towards that? If the problem is walking there, help with some graded exercise suggestions. If the problem is standing, do they need maybe to see a physical therapist to work on posture, or do they need a cane? You know, how can we help get you there? Okay, so this is the conclusion of my case, because I did tell you that this is a real person, and this is what really happened with the woman this is based on. So we were able to completely discontinue her morphine SR without any adverse effect on her pain. And we went down one 15-milligram pill per month to zero. It took, I guess it wasn't every single month, so this took maybe up to a year. Got her hydrocodone decreased from eight to four tablets a day, so she's still on 20 morphine-equivalent milligrams per day. But that's a lot lower than 130. And I got her zolpidem cut in half, but not completely off. Over the course of this paper, her pain and function really did not change. So she's not so vastly better, but she's definitely not worse, and she's clearly on a lower-risk regimen. And her visits are really focusing on her lifestyle change efforts. So we're not talking about pain intensity. We're talking about her goals and what she's doing or not doing to achieve those. So this is a situation that we often see in real life. We don't have 100% success, but, you know, I am willing to claim victory if I've reduced somebody's risk of harm and, you know, at least help them kind of think about their problem in a way that might be more empowering in the long term and might help them over time get towards improved quality of life and function. All right. So, in summary, patient-centered opioid management really represents a commitment to respecting patient preferences, needs, and values, and it incorporates their experiences and the individual assessment of care. It is not a commitment to continue potentially harmful or ineffective therapy. So three steps to opioid reduction in a patient-centered manner are, first, to develop that individual benefit-harm assessment, second, to share decision-making about options that exist, and third, to implement a taper trial with the patient. And I've not talked at all about the pharmacology or specific dosing of doing an opioid taper, but there is another webinar in this series, Opioid Pharmacology and Dosing Management, that does include more specific information about tapering opioids. These are the references, and I do want to make you aware of a couple of resources. So, first, the PCSSL Colleague Support Program is available to really pair clinicians with mentors who are part of a national network of trained providers with expertise in addiction medicine, psychiatry, and pain management. And the idea is that this would really provide individualized, unique help with whatever kind of problems you might be facing in your practice. This is available at no cost, and more information and the ability to request colleague support is at the link listed there. If you're looking for more focused answers to questions, the listserv for PCSSO is an opportunity to do that. There is an expert of the month who answers questions. So, if you have any questions after viewing this webinar, you can join the e-mail at PCSSO at aap.org. And this is simply a little information about this webinar series, which includes a variety of talks on important topics related to opioid therapy, pain management, and addiction. Thank you for your attention, and I appreciate you watching this webinar today. Bye-bye.

Dr. Erin Krebs

communication success

opioid management

patient-centered care

shared decision-making

taper trial

individualized care

healthcare professionals

case study