Starting a conversation about opioid tapering with patients
Practice tips for GPs and pharmacists
Starting conversations about opioid tapering can be challenging
Try these approaches:
- Use the term ‘pain medicines’ rather than ‘pain killers’. In chronic non-cancer pain there is no such thing as a ‘pain killer’,1 and this term may give patients the impression that they will be pain-free.
- Ask ‘how’ and ‘what’ questions, instead of asking ‘why’ (eg, ‘How do you feel about using this medicine?’, ‘What aspects of using this opioid are you not so happy about?’) Starting with ‘why’ invites the patient to rationalise their current actions and give excuses, rather than more factual accounts that can provide a basis for possible intervention.1
- Use language that builds relationships and reduces stigma.2 For example: refer to the pain, not their/your pain, say ‘a person with chronic or persisting pain’ instead of ‘a pain sufferer’. Terms that judge (eg, ‘good’, ‘bad’) could make patients feel they shouldn’t use opioids even when they are appropriately prescribed.
- Find out how much patients understand about the risks of long-term opioid use and tailor messages about tapering to suit each patient’s circumstances. Patients may not believe the risk of opioid misuse applies to them personally,3 and risk of overdose has not been found to be a primary motivator for opioid tapering.4
- Avoid scaremongering when discussing the risks of opioids. Present facts that do not vilify opioids, and deliver an appropriate message about the risk for each patient which could lead to a conversation about tapering.
- Discuss non-medicine alternatives to help when tapering and ensure the patient feels supported.
Approaches to the conversation
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What do you know about the long-term use of opioids? What do you feel are the upsides and downsides to continuing to take opioids? |
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“Opioids work well to relieve short-term pain. However, the longer you use an opioid, the less well it works and sometimes it can even make the pain worse. Your body and mind get used to the medicine, and over time you may feel like you need more medicine for the same amount of pain relief. This can actually be an indication that they are not working well for you any more.” |
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How do you see yourself in a few weeks/months time if you were able to reduce/stop the medicine? We can think about other strategies to help you manage the pain, so that we can reduce the amount of medicine you have to take. How do you feel about that? |
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“Research shows strong evidence for the lack of effectiveness of opioids in chronic non-cancer pain. Opioids are a bit like scaffolding and should only be used to help support you to get started with other ways to manage pain. Once these approaches are established, the aim is to lower the dose or stop them completely. Now might be a good time to start thinking about reducing your dose. Dose reduction can improve function, quality of life and pain control. You may be more alert and therefore more connected and engaged with others around you.” |
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What worries you about reducing your opioid dose? |
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“For some people, thinking about lowering their opioid dose can feel very scary, especially if they have been taking them for a long time. But be reassured it’s never too late to try.” |
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How do you feel as we talk about reducing your medicine? |
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“Dose reduction won’t happen overnight, and the time it takes depends on how much you take and your own personal circumstances. The pain may briefly get worse at first, and you may experience unpleasant side effects. You may feel that taking the medicine as before can relieve these effects. This is expected because of the way your mind and body has adapted to the medicine. But we can make sure that your pain management is as safe as possible, and that you experience improved function with a lowered dose.” |
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“There are also many different strategies and services that will be part of the dose reduction plan, that form part of pain management for you, now and in the long term.” Refer to the Opioids Resources list for services and strategies available (eg, tapering plan). |
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Let’s focus on your goals. What do you want to be able to do day-to-day that you can’t do right now? |
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“Your goals can be as simple as walking a little further every day, gardening, walking the dog around the block, or standing up and sitting down without pain. The main aim of pain management is not necessarily that you have no pain at all, but that you can still function daily, at the level of pain that you may have that day.” |
References
- Analgesic Expert Group. Therapeutic Guidelines: Analgesic. Version 6. West Melbourne: Therapeutic Guidelines Ltd, 2012 (accessed 10 January 2019).
- painaustralia. Chronic pain language guidelines. Canberra: painaustralia, 2018 (accessed 22 July 2019).
- Matthias MS, Johnson NL, Shields CG, et al. ‘I'm not gonna pull the rug out from under you’: Patient-provider communication about opioid tapering. J Pain 2017;18:1365-73.
- Frank JW, Levy C, Matlock DD, et al. Patients' perspectives on tapering of chronic opioid therapy: A qualitative study. Pain Med 2016;17:1838-47.
- Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm Rep 2016;65:1-49.
- Geurts JW, Willems PC, Lockwood C, et al. Patient expectations for management of chronic non-cancer pain: A systematic review. Health Expect 2017;20:1201-17.