To: Healthcare Providers
From: California Department of Public Health Statewide Opioid Safety Workgroup
Date: August 27, 2019
Re: Don't Drop Your Patients and Tapering of High Dose Opioids
For the full Health Advisory, please visit: https://www.bgmsonline.org/site/assets/files/1184/dontdropyourpatient_9_11_19.pdf
Health care providers are essential partners in ending the opioid epidemic in California. Working together, we want to ensure that providers have access to resources and support to help improve patient pain management, while avoiding opioid overdose and dependence.
One of the most challenging situations reported by prescribers is how to respond to patients already on high doses of opioids (> 90 MMEs) or with possible addiction symptoms. These patients are at higher risk and may need your assistance more than ever. Recent concerns about over-prescribing of opioids has led to some misinterpretation resulting in abruptly terminating the use of opioids, which can cause health risks for patients. I want to stress that some pain management situations may involve the use of opioid medications if alternative approaches are not available or effective. It is my hope that we can offer resources to support you as you continue your clinical relationship with your patients to ensure their overall well-being.
On behalf of the Statewide Opioid Safety (SOS) Workgroup and partners, I am contacting you to offer resources to assist you in addressing these critical treatment issues with your patients:
- Consider all pain management options before starting patients on opioids.
- Recognize when and understand how to taper patients at risk.
- Offer medication assisted treatment (MAT) to your patients.
- Provide patient referrals to MAT and addiction recovery programs.
Please visit the link or access the QR code to find resources on each of these topics. Summary information on each topic is included below.
Consider All Pain Management Options before Starting Patients on Opioids
The Centers for Disease Control and Prevention (CDC) recommends exploring multiple treatment options (including non-pharmaceutical alternatives) to address chronic pain management before starting patients on opioids. Speak with your patients’ health plans to find out what alternatives are available.Recognize When and Understand How to Taper Patients on Opioids
Health care professionals should not abruptly discontinue opioids in a patient who is physically dependent on opioids, nor should they implement rapid tapers in patients with long-term dependence. Safe tapers may take months to years to accomplish. Ensure patients understand the risks and benefits of dose maintenance versus dose tapering and develop an individualized plan in collaboration with patients.
The CDC recently clarified that its 2016 guidelines only recommended dose limits for new patients. The CDC does not recommend applying arbitrary dose limits to patients dependent on long-term opioids, as there is insufficient data supporting this practice. In a recent study in the Journal of Substance Abuse Treatment, after an abrupt taper almost half (49%) of people had an opioidrelated hospitalization or emergency department visit. 1Offer Medication Assisted Treatment (MAT)
For patients experiencing opioid use disorder, the use of some MAT, such as buprenorphine, has been shown to be highly safe and effective in lowering overdose risk, decreasing HIV and hepatitis C occurrences, and increasing retention in treatment. If you are not yet certified to prescribe buprenorphine, consider obtaining X-waiver certification. There are several short online MAT training programs available as well as additional MAT treatment resources for X-waivered health care professionals on our resource list.Additional support on MAT and other substance use disorder questions for clinicians is available through the California Substance Use Line – Staffed 24/7 in collaboration between addiction experts at the UCSF Clinicians Consultation Center and California Poison Control: (844) 326-2626. Provide Referrals to MAT and Addiction Recovery Programs (Locator Tool)
If you are unable to provide MAT, refer patients to a drug or recovery program within your community. Use the treatment locator tools on the Opioid Prescribers Resource sheet to find local MAT and addiction recovery services.
For patients who use opioids or other drugs non-medically, harm reduction programs provide a range of supportive, nonjudgmental services to prevent disease transmission and overdose, offer substance use counseling, and help people connect to and stay engaged with health care. A directory of harm reduction programs in California is available on the Opioid Prescribers Resource sheet.
Thank you for providing quality medical care to your patients.
Sincerely, Charity Dean, M.D., M.P.H.
Acting State Public Health Officer