Hi, I'm Erin Krebs. I'm a General Internal Medicine Physician at the Minneapolis VA and a Professor of Medicine at the University of Minnesota. I'm going to be talking today about keys to communication success in opioid management. The next couple of slides here are from PCSS, housekeeping and disclosures, which I will let you read. This is the standard disclosure. I should say that I do not have any commercial interests here. My perspectives are my own in this talk, and they have been developed through quite a few years of experience with my own patients as a primary care physician. With other people's patients as someone working in a collaborative care team to deal with some sticky opioid issues. And in my research studies, taking care of patients who are participants in trials. The educational objectives here today are first to recognize patient perspectives on opioid management and specifically tapering. Second, to identify practical approaches to limiting, reducing, or discontinuing opioids while maintaining a positive patient clinician relationship. And third, to describe the role of shared decision making in opioid tapering. I'm going to start with a case that will continue throughout this talk. This is a new patient in your primary care clinic presenting for transfer of care. She's a 50 year old woman and her chief complaint is needing pain medications refilled. The problem list on the chart includes chronic back pain on opioids for more than 15 years, depression, insomnia, type 2 diabetes, sleep apnea, and smoking. This is not an atypical problem list in my clinic. This patient's medications include morphine, sustained release, 30 milligrams three times a day, oxycodone, acetaminophen, 8 tablets per day, and clonazepam, 2 milligrams at bedtime for sleep. The patient reports that nothing has ever helped for her pain and sleep except for her current medications. She reports that she's using them as prescribed, that she doesn't use alcohol or any illicit drugs, including no marijuana. You have access to the chart from the office of her retired physician. And in general, it looks like she attends her visits, has been broadly adherent to therapy. The PDMP report and the urine drug screening test results are appropriate and consistent with adherence with prescribed medications. So what should you do next? A, continue current opioids because the patient reports they are effective and there is no evidence of misuse. B, tell the patient the risk of overdose is very high with this regimen, so you need to start tapering today. Or C, discuss with the patient the potential risks, benefits, and side effects of opioids and assess the patient's readiness to start tapering opioids. Well, the answer here is C, probably not too much of a mystery. This is the option that is consistent with patient-centered opioid management. This presentation is grounded in the concept of patient-centered care. Some have worried that patient-centered care is inconsistent with safe opioid management, but I do not see it that way. Patient-centered care has been defined as care that is respectful of and responsive to individual patient preferences, needs, and values. Note that that is not the same as a customer service activity or an alternative to evidence-based care. I would define patient-centered opioid management as care that considers the evidence of potential benefits and harms in the context of patient values, goals, and individual circumstances. Importantly, guidelines do support the idea of patient-centered opioid management. I'm just going to briefly highlight the CDC Opioid Prescribing Guideline, the most recent version published in 2022. It includes a recommendation. If the benefits do not outweigh the risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower doses. Or if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. So really just want to emphasize the statements here that include work closely with patients and individual circumstances of the patient. So this is not a recommendation for across-the-board tapering based on some sort of threshold. I'm presenting a case here today where the patient is not wanting to reduce her opioid use. So the question comes up, why would we taper long-term opioids in this case? I commonly hear this question from both patients and clinicians about why we should taper when patients appear to be stable on opioids without any kind of immediate hazard or strong indication for dose reduction. There are both individual and general reasons why tapering should be considered, I think, for everyone on longer-term opioids, especially high-dose opioids. The first possibility is that maybe there's a change in the patient's situation. I mentioned this patient has been on opioids for 15 years or more. A lot can happen in that time. For one thing, her primary initial chronic pain situation may have evolved over time, but often there are other changes. Simply aging changes the risk-benefit ratio because the same dosage with an aging patient and changes over time in drug metabolism may increase the risk of harm. Another possibility is a new comorbidity that may increase the level of risk. There are also opportunities for change on the positive side. An example of an opportunity is a plan for future surgery, such as joint replacement. Most patients with chronic pain who are thinking about a major orthopedic surgery are hoping that they're going to have less pain and possibly less medication need after the surgery, so it's just a moment of optimism. I also tell patients that there's a fair amount of evidence that perioperative pain control and surgical outcomes are worse when people are on preoperative opioids, especially high-dose opioids. Getting the opioid dose down somewhat before the surgery may help both with perioperative pain control and recovery and with potentially getting the opioids down to the ultimate goal after surgery. There are also a couple of general reasons to consider tapering for pretty much all patients. At least talk about it and think about it. The main general reason why I seek to taper opioids is because long-term opioids have very limited benefits for patients with chronic pain. In general, as a principle, we should not continue medications that don't provide clear benefits. The next reason to continue is that risks of opioid harms do increase with both duration of opioid use and with the daily dosage. I'll talk a bit more about these individual, general, broadly applicable reasons on the next few slides. In terms of limited benefits in chronic pain, I think it is important to first acknowledge that we really do have good evidence that opioids have small benefits compared with placebo for both pain and function. They are better than nothing, at least at first. Benefits seem to be less over time, smaller in studies with more than three months follow-up. Truth be told, almost all of the studies here are short-term. We have very few placebo-controlled long-term studies. On the other hand, we have moderate to strong evidence that opioids are not better than non-opioid medications for pain or function. For many patients, although the idea is that these may be the best medications, often they are not. We also know that adaptations to long-term opioid use diminish benefits over time. Often they diminish those benefits to zero. That's because tolerance to the analgesic effects of opioids develops very rapidly in most people. With increases in doses, generally the tolerance levels up once again. Duration-related harms of opioid therapy are really important. I often think we underestimate these as a problem for patients on long-term opioid use. Specifically, the normal physiologic adaptations that people go through when they take exogenous opioids on a long-term basis. These adaptations to long-term opioid use can make it very difficult to decrease or stop opioids, even when they are not beneficial for pain. Long-term use of opioids generates a physiologic need to continue taking opioids to avoid withdrawal symptoms. This physiological state is also known as opioid dependence. Here I'm not talking about opioid use disorder or addiction. This is a little confusing because the DSM-IV used to refer to what is now known as opioid use disorder, as opioid dependence. Addiction, or OUD, involves features related to compulsive use and loss of control of opioid use. I am not talking about that. I'm talking about the simple physiologic state where one must continue using opioids to avoid withdrawal. I think of this as analogous to the adrenal insufficiency that can happen when we treat people with exogenous corticosteroids. We all have an endogenous opioid system. I don't think we fully understand what can happen to that endogenous opioid system when we treat with higher-dose, longer-term exogenous opioids. The opioid withdrawal symptoms patients are trying to avoid by continuing opioids include not just the acute withdrawal symptoms that we often think about, but hyperalgesia and a hypersensitive negative emotional state that may be persistent for patients. We really don't know how long this can last. Perhaps it can be indefinite, but it does seem to be lasting for many people much longer than those short-term acute withdrawal effects. Finally, dose-related harms I think are familiar to most people at this point. It's well known that for patients who receive opioids, overdose and deaths do increase with higher daily-dose concurrent benzodiazepines and use of long-acting opioids as opposed to short-acting opioids. Higher prescribed opioid daily doses predict not just death, but also incident and recurrent major depression, incident opioid use disorder, and road trauma. And the relationship between dose and harms is continuous, meaning there is no particular cutoff at which harms suddenly escalate. As doses increase, harms increase too. This is really in contrast with pain relief. As far as we know, higher doses do not lead to more pain relief, again, due to that development of tolerance. Many observational studies have found that higher doses of opioids are associated with worse pain severity among patients who are receiving long-term opioids. Although we know a lot about the harms of opioids, you know, we really don't know that much about outcomes of opioid reduction. Systematic reviews have looked at this and found overall low-quality evidence on patient outcomes of opioid dose reductions. There are some themes, though, in the evidence. First, that studies of opioid tapering occurring in the context of intensive and very supportive pain programs, in general, those studies find improvements in pain and function, along with decreases in opioids. Studies of opioid tapering that is occurring in the context of less intense support or no support at all have found either small improvements or really unchanged pain and function with opioid dose reduction. On the other hand, some large database studies have found an association of reduced opioid dose or discontinuation with serious harm, such as overdose. This brings me to some important cautions. First, opioid withdrawal can cause severe psychological distress and worsen pain in patients who've been taking long-term opioids. As I mentioned earlier, the duration of this effect is unpredictable, and so is the severity. So you just really have to be aware that it is not necessarily a simple thing to decrease opioid use. The other big caution here is that tapering or discontinuation of prescribed opioids is not a sufficient response to suspected opioid use disorder. If someone has opioid use disorder, they need medication treatment of opioid use disorder. They need appropriate treatment. That's the standard of care because it reduces mortality and improves quality of life. Simply stopping opioids in the context of opioid use disorder may lead to much worse outcomes. So this presentation is really about opioid tapering when opioid use disorder is not present. I do encourage you to always, as you're taking care of patients, consider the possibility of opioid use disorder and make sure that's being addressed. I'm going to move on to the next part of this talk, which is patient perspectives. On the next few slides, I'll summarize findings from a series of qualitative studies using in-depth interviews with patients and physicians and observations of clinic visits. I'll also present from quotes from these studies to illustrate my points. Probably the strongest theme in qualitative studies about patients with chronic pain, including those prescribed opioids, is that patients really want us to ask about pain and seek to understand how pain affects them in their lives. As one patient said, this is nothing against my provider, but 99% of the conversations we ever have, because it's only every six months or once a year, is my physical, my weight, blood pressure, what number of pain I'm in, but there is no conversation about pain. This is such a strong theme, I think, because we often don't ask enough questions or spend enough time listening to the pain concerns of our patients. Empathetic listening is an important therapeutic intervention, and often it is a precondition to other interventions being effective. If a patient gets the impression that you are not interested in their pain or you're minimizing their experience, that undermines their trust in you, your relationship, and the opportunities for effective care. Demonstrating your interest and caring about how pain is affecting a patient's life can really help with successful opioid management. The next theme that is extremely common is that patients want individualized care. Again, common in many studies of pain patients, but particularly important when it comes to conversations about limiting, reducing, or discontinuing opioids. As one patient said, I'm not taking a high dose, not asking for more. It's not like I go to them every six months and say, hey, I need more. I don't do that. I know what they say is correct for some people, but it is not going to work for me. Especially in the environment where there have been a lot of policies and initiatives aimed at reducing opioid use across the healthcare system, across healthcare systems and across the country, patients are very aware of this and sensitized to the possibility that you're making changes based on some sort of external force and not based on your concern for them and what is best for their well-being. So I do just think this is very important to keep in mind. The third theme I want to mention here today is that overdose concerns may not be salient to patients. The truth is we as clinicians are often very motivated by concerns about overdose and other serious harms, but patients often are not. These quotes are from two patients. The first one did not see overdose risk as applying to them at all. They said, the concern is that if they increase my opioid dosage, I could stop breathing. It's ridiculous. The second quote is from a patient who didn't feel that it was important, even if the risk did apply. My provider said you could die any time. And my husband and I said, well, we realize that, but because of the pain, you know, we are willing to take that risk that I would die from the narcotic medication. And that's because the fear of worsening pain for this patient was worse than the fear of death. This slide is about patient priorities and based on a number of studies that have asked patients about what they would like to see in pain management in terms of outcomes and also about experiences with opioid therapy. In general, patients with chronic pain have many priorities for pain treatment. They hope effective pain management will lead to a host of other improvements, such as improvement in enjoyment of life, reduced fatigue, emotional well-being, better sleep, physical activity, improved concentration and memory, and improved participation in social activities, just to name a few. Of course, these things are often well beyond the power of medications, which is why the most effective pain care involves behavioral approaches, exercise, and other non-drug treatments. Unfortunately, opioid therapy often has side effects that actually undermine pain treatment priorities. So these are some of the undesirable outcomes of opioid therapy that are most commonly reported by patients. Drowsiness, trouble concentrating, fatigue, memory problems, dry mouth, nausea, constipation, and of course, as we mentioned earlier, dependence on medication. I think it's important to talk through this with patients, help them make the connection. We're really trying to improve their overall well-being and quality of life, not exchanging one problem for another. In my experience, many patients who seem to be experiencing negative effects of opioids do not have concerns or acknowledge concerns about opioids. In some cases, this may be because patients are not aware that opioids are responsible for the negative effects on their life. They may think it is a different cause or due to the pain itself. In other cases, patients may not be willing to disclose their concerns to you because they may not trust us to act in their best interests. Data on this slide are from a survey of health plan enrollees receiving opioids. Among patients in the survey who rated opioids as at least moderately helpful, 43% also said they wanted to stop or cut down on opioids. And that's the column labeled desire to reduce. The other majority of patients did not want to cut down on opioids. Patients completed a measure assessing their opioid-related problems and concerns. This table shows some of their most common concerns among these patients. All of the concerns were more common among those who wanted to cut down on opioid use. So patients who are drawing the connection between side effects and opioids have more desire to reduce their use. Now I'm moving on to the next section, which is practical approaches to opioid dose reduction. Now I'll start with some practical advice, just some key points to keep in mind as we talk. First, assess the benefits and harms of opioid therapy while seeking to understand the patient's pain experience perspective and goals. This is getting back to that patient-centered concept. Second, think about the level of urgency for change and calibrate your approach to that level of urgency. If there is no imminent risk of harm, it's probably worth taking the time to develop a collaboration with patients, even if you aren't able to start tapering as soon as you would like to. Third, be transparent with the patient about your assessment and plan, and just as importantly, document your thinking very clearly. Share as many decisions as possible is the last point, and I'll spend some time talking about that. This slide is a flowchart from the HHS Guide to Opioid Reduction, which is a good resource that I highly recommend. There's a link at the bottom of the slide, and this is also referenced at the end of the talk. The key point I'm trying to get to with this slide is just that the first step to opioid tapering is conducting a benefits and risk assessment, and that's what I'll talk about now. Assessing benefit sounds simple, but is a deceptively difficult task, especially if you did not know the patient before opioids were started. Usually, there has been no structured assessment of pain outcomes over time, so the chart may not tell the story. Patients who are benefiting from opioids, who are not benefiting from opioids, may believe they are for many reasons. Maybe because of the memory of the initial pain relief they experienced, fear that they would be worse off without opioids, belief that maybe they're just not on the right dose, a higher dose or a stronger opioid would work better. Also some patients have experienced brief times without an opioid, for example, delays in refills, and they believe that increase in pain caused by withdrawal represents their natural opioid-free state. For most patients who have been taking opioids around the clock for a long time though, benefits are likely minimal or nonexistent. I try to assess benefits by focusing on functioning and whether the patient is currently meeting their life goals. And these are some of my favorite questions that I ask. They're good for identifying current benefit of opioid therapy and also good for identifying goals of changes in therapy. So I often will ask about activities and limitations. Are there things that are important to you that you don't do because of your pain? Or if they do see themselves as having difficulty with opioids or problems due to opioids, I may ask if there are things that are important to do that they don't do because of opioids. A common one is patients will say, I don't travel anymore because I'm afraid I'll run out of my opioids and have withdrawal symptoms. I like to ask, what would your life be like if you didn't have this pain? Or alternatively, if your pain was well-controlled. And then just to get really into the nitty-gritty and understand their day-to-day, I'll ask them to tell me about a typical day. What did they do yesterday? This helps me find out if they're spending a lot of time in bed or on the couch or if they're having an active lifestyle. To try to clarify effective opioids, I ask them broadly how their pain medications are working. That's a hard question for a lot of patients to ask. And I try, regardless of what they say, to really dig in, asking them to define more what they mean. What do you mean when you say it takes the edge off? Or what do you mean when you say that you couldn't live without it? Assessing harm is a bit more straightforward than assessing benefit. There are four ways to look at this. Assessing adverse symptoms, so side effects. Assessing risk factors for major harm. Assessing evidence of problematic opioid use or misuse. And finally, assessing for evidence of actual current ongoing harm. As I mentioned earlier, the most salient harms often differ for patients and prescribers. We tend to be worried about opioid use disorder and death. Patients tend to be worried about other things. In terms of understanding common adverse effects or side effects, these are some of the things I think about. Whether opioids could be causing or contributing to bothersome symptoms that the patient reports, such as withdrawal from social engagement, poor concentration, focus, or memory, low motivation, depressed mood, constipation, nausea, headaches, which can be a special case sometimes with migraines in particular, analgesic overuse headaches can be a big issue. Sexual dysfunction is another one. And wondering, you know, could opioids be interfering with a patient's life and their goals? If we define major harms as overdose and opioid use disorder, risk factors include both treatment-based factors and patient factors. So the treatment factors include, as I already mentioned, higher dose, long-term opioid use, concurrent sedative-hypnotic use, and use of long-acting or extended-release opioids. Those have all been associated with overdose and opioid use disorder. Patient conditions such as substance use disorder in the past or present, mental health conditions, and also high pain severity and impairment have been associated with major harms. Awareness of problematic opioid use is another important thing to evaluate for. Behavior that suggests increased risk of harm to either the patient or the community can be detected through medical record review, drug testing with or without pill counts, and prescription monitoring program database reviews. I think it is always important to remember that observed non-adherence or misuse behaviors may have a lot of different causes, including substance use disorder, mental health conditions, dysfunctional pain coping, opioid-induced behaviors related to that tolerance, dependence, and withdrawal situation, or just social chaos or difficulty. All of these causes do suggest increased risk for harm, but the appropriate clinical response may differ depending on what is actually underlying the issues you observe. I think it's particularly important, again, to make sure that you have a high level of suspicion for opioid use disorder and make efforts to make that diagnosis, if present, because that does indicate a need for treatment with medications for opioid use disorder, such as buprenorphine, not just opioid tapering. If problematic behavior is identified, be transparent with the patient about that and make sure to address the problems in terms of concern for their well-being. I recommend giving specific and timely information about why you are concerned. I'm worried about you because your urine drug tests suggest you might have a problem with cocaine and maybe not using your opioids as prescribed, for example. Always when you're talking about it, blame the drugs, not the patients. So I would say, I think these medications are hurting you more than they are helping, rather than I think you are using these medications wrong, and that is causing the risk. State your plan and any options that you want to offer the patient very clearly. So if you've made a decision based on what you've observed, tell the patient. If you've observed concerning symptoms or signs, but you're not sure what the underlying issue is, I would tell the patient that. Tell them you are concerned and you need to monitor them more closely to understand what's going on. I find that nothing is more illuminating than increasing the visit frequency. Having somebody come in really regularly can really help you understand the underlying problem. If you are tapering, I would consider much closer monitoring and support if you're seeing non-adherence behaviors. If addiction is present or emerges during the taper, make sure to provide or offer treatment. Getting back to our patient that I mentioned at the beginning of this talk, our 50-year-old woman who needs her pain medications refilled, and as a reminder, those included morphine, oxycodone, and clonazepam. Through additional history taking, you learn more about this patient, including that she is not working and lives on disability payments, that she's a single parent of two, and she struggles as a parent. In particular, she's not able to be as present for them as she would like to be. She really doesn't have any good friends or any hobbies anymore other than watching TV. She feels people don't want to be around her because she is down, depressed, can't do anything, hurts all the time. She feels hopeless about the future and says, I'm going to end up in a wheelchair. The best description of how opioids work for her is that they take the edge off. Remember, she said she couldn't live without them before, but truly they are probably not providing much benefit here. So I would categorically say to her that I do not think opioids are working well for her, and I say that because this is not what successful pain management looks like. Her life is very constrained, and her function is severely impaired by pain, despite this very high-dose opioid regimen. I would document my assessment clearly as shown on the slide here, that her pain is poorly controlled and interferes with social, occupational, and physical function, that opioids appear to be effective and are not meeting treatment goals. I would clearly say to her and document that her risk factors for serious harm, such as overdose or addiction, include high dosage of opioids, the combination with the clonazepam, depression, and sleep apnea. I would tell her and write in the chart that I don't see any evidence of misuse, and I don't currently have any evidence of opioid use disorder. I would tell her and write in the chart that opioids may be contributing to depressed mood, low motivation, and social disengagement, and that overall I see the risks and harms of opioids as outweighing the benefits for this particular patient. That said, the short-term risk of serious harm is relatively low, because there's no sign that she's experiencing overdose precursor symptoms. She's been taking these medications for a very long time and does have tolerance. Shared decision-making is the next step with this patient. She's already told you that she doesn't want to reduce opioids. She wants you to refill them. So I'll start with a brief definition of shared decision-making. This concept, I think, is most often discussed in the context of focused, intensive, one-time decisions such as whether or not to undergo cancer screening or whether or not to undergo a major surgery. That is just not how it is in opioid tapering. Instead, shared decision-making in this context is an iterative process involving sharing of many small decisions. Importantly, you do not have to put every decision on the table for discussion with a patient. Some decisions can be shared, even if other decisions are not. At its basic, shared decision-making involves three core tasks. The first one is sharing information both ways. The second is deliberating about options. And the third is agreeing about a course of action. I'll go through these three steps. But first, I think it's helpful to think about the degree of shared decision-making. The degree of decision-sharing can be thought of as being on a continuum from decisions made entirely by patients to decisions made entirely by prescribers. And although we don't think about it very often, a lot of opioid discontinuation decisions are made by patients alone without any input from prescribers. This often happens because patients simply decide that the side effects outweigh the benefits for them personally. Or they develop some kind of concern that leads them to taper or just abruptly stop their opioids. On the other hand, there are decisions that should be made 100% by the prescriber. I think these are the highest risk situations and where the decision to stop prescribing is simple. For example, if you are very confident a patient has been diverting opioids and not taking them themselves, it's pretty easy to stop the medication. But really, in reality, I think most decisions are probably prescriber-initiated but involve patients. Few decisions are perfectly 50-50 equally shared. And I do want to make a point here that I think that tapering should be collaborative even when it is not entirely voluntary. Often we do need to make a decision that we shouldn't continue prescribing the way we have in the past or the way another clinician has in the past. I will often say things like, as a physician, it's my responsibility not to continue treatment that I think is ineffective and putting you at risk. When I say something like that, I often will also reassure the patient that I'm not trying to make any sudden moves or pull the rug out for them. I just want them to know that I don't plan on continuing this long-term. It is very important to own this decision, even when it is uncomfortable, and not blame it on policy or third parties. The truth is there are often policies that do push us toward dose reduction now. And if there is a policy in place that affects your decision making, I would be straightforward about that. And I think you can still own the decision and frame it in individualized terms. For example, I could say it's true that your insurance is pushing for lower doses, but I also agree that it's in your best interest to make a change and then give the reasons why. As I talk about decisions where I'm leading but also hoping to provide some sharing, I will say I'm not going to give you the option of continuing the status quo as it is, because I don't think it's safe or effective. But I will work with you and I'll give you as many options as I can. Getting back to our case patient, this case is a case of prescriber-led, patient-involved tapering decisions. I mentioned at that first visit that this is a patient who is wanting her meds renewed. How I would document the plan at that visit is that I would say, discuss the risks of the current regimen with the patient, and I recommended dose reduction. She is not ready to taper. Plan to follow up in one month to discuss tapering and non-opioid pain management options. Sometimes I also document that although the long-term risk of continuing this regimen is high, the short-term risk is low, and that abrupt discontinuation also would increase risks, just to make it clear in the chart why I'm doing what I'm doing. Step one of shared decision-making is information sharing. I already talked about how you should explain your assessment and treatment goals, but a big part of this, probably the most important part, is asking questions of the patient and listening to them, asking, after you tell them you would like to reduce their opioids, what do they think about that? Have they tried to cut down before? Do they have concerns about reducing opioids? Do they see any potential benefits? This step can take some time and often multiple visits. In the case patient who I'm talking about today, it took me four visits over six months before we got to the first step of dose reduction. I think of this as really building the foundation for tapering, since the sharing of information has to be bidirectional. It's important also that you make recommendations that are tied to the patient's well-being. These should emphasize the goals and activities important to the patient. And if you have a specific dose endpoint in mind, I think you should say so. If you aren't sure, say that as well. I often tell people I want to reduce your dose, but I don't know the best endpoint in terms of the best dose for you going forward. I just know that it's lower than what we have right now. It's important to talk about expectations for tapering and counsel patients about what this might be like for them. I try to always tell people they may have a temporary increase in pain or mood symptoms after dose reduction. That's due to withdrawal, not because the opioid was necessarily working, and it should improve over time. As long as we go down slowly, I tell patients that I don't expect any overall change in your level of pain. My goal is that maybe your pain stays the same and you end up with less medications to take and fewer side effects. I tell people that most patients eventually feel better on lower doses, and that includes feeling more clear and more energetic, but it can take time to see those benefits. So we just go as slow as we need to go. Again, this is a lot of information that can take some time to impart to patients. It's not a single visit situation. I think taking the time to talk through these things and wait shows commitment to caring for the patient. Part of that is scheduling follow-up to talk about it again, providing contact information so they can reach you if there are any issues, and expressing a commitment to reevaluating how things are going along the way once you do get started with tapering. The next step is deliberating about options. In most cases, there are a lot of small decisions to be made, and many of them can and should be shared. I already told you what I say when I'm making the decision to start tapering, but then I do tell people we have other options, including which medication to reduce first, how quickly to step the dose down, when to follow up. I also like to focus on other things, so shared decision-making about non-opioid pain treatment and goals for self-management. I think it's important to talk about how a patient is going to do self-care if they're having some mild withdrawal symptoms or difficulty adjusting to a lower dose of opioids. Just talking through that in advance can reduce anxiety about it. Often patients have very strong opinions about which medications to reduce first, which ones are most helpful. In this patient situation, they have the clonazepam, the morphine, and the oxycodone, so really reducing any of those would be good. I typically let patients choose. If they do not care, I recommend reducing the long-acting opioid first, because I generally think they're worthless, and most people don't notice much change in their pain when those decrease. When to start is probably the most important decision, and again, I don't force the start of a taper immediately. I'll discuss it at several follow-up visits before I finally get to the push. I may end after several conversations say something like, we've been talking about this for a while, I'm going to want to make a change at our next visit if you're not ready today. Step three in shared decision-making is agreement on a course of action. Again, this can be one small decision at a time. Just make sure you're on the same page about what you've agreed on and that it is clearly documented. I try to be very clear about these things. So for this patient who was on morphine SR three times a day, the example might be, decrease your morning morphine dose by one tablet. Your new dose will be 15 milligrams in the morning, 30 milligrams in the middle of the day, and 30 milligrams in the evening. And then, because I do like to do self-care goals, I would say walk for five minutes every day after lunch, and then we'll plan on following up in four weeks before we make the next dose change. This is the resolution of the case of the patient with chronic low back pain. Ultimately, I did taper her opioids to a much lower dose over about three years. First we tapered off the morphine SR, then we gradually reduced that oxycodone to three tablets per day. The taper was paused several times due to a variety of issues, individual stressors, mental health challenges. But over time, the decisions gradually shifted to patient-led. We kind of got into a rhythm with it. So I would, you know, at first it was always me saying it's time to go down, and eventually she started saying, I think I'm ready for the next dose reduction. I did continue to prescribe opioids for this patient, actually still do, I have a person in mind, and she is on much lower doses of oxycodone PRN only. Outcomes here, she does still have pain that is in the moderate to severe category, but it is not at all the focus of her life in the way that it used to be. Her pain coping and her self-care is much improved. Her physical and her social function are also much better. This particular patient, I had the joy of having her daughter come in and tell me thank you because she got her mom back as a result of the opioid tapering. So these are my three big takeaways. First, patients want clinicians to listen and treat them as individuals. That's always true, but it's especially true in chronic pain, and even more so when opioid dose reduction is involved. Patient and clinician priorities often differ. It's important to focus on patient priorities because it's better for everybody and it really may improve their engagement and their outcomes. Finally, unless serious harm seems imminent, make sure to take the time to develop a collaborative tapering plan, even if it isn't entirely voluntary on the part of the patient, and share as many decisions with patients as you can to empower them to contribute to their own health. These are a bunch of references in tiny font that I hope may be helpful. And my last task here today is to plug some of the PCSS resources, which can be really valuable, their mentoring program explained here, and their discussion forum as well. This is a collaborative effort led by the American Academy of Addiction Psychiatry in partnership with a whole lot of different organizations. Thank you for your attention. I appreciate it.

substance use screening

primary care

screening tools

Dr. Jennifer McNeely

American Psychiatric Association

TAPS tool

US Preventive Services Task Force

implementation barriers

referral and treatment

opioid treatment

patient-centered approach

opioid tapering

shared decision-making

chronic pain management

opioid dependence

empathy in healthcare

collaborative process

opioid management

patient-centered care

chronic pain

patient-clinician relationship

quality of life

holistic care