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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

19-489 Taper Off Opioids to Avoid Harm

Date: 06/19/19

The U.S. Food and Drug Administration (FDA) found harm reported from quickly stopping opioids and requires label changes to guide prescribers on gradual tapering

Providers should not abruptly stop opioid medication for a patient who is physically dependent. Instead, when you and your patient agree to taper, think about dose, duration of treatment, the type of pain being treated, and the patient’s physical and mental well-being.

Since no opioid tapering schedule fits all, create a patient-specific plan to slowly taper, and monitor and support as needed to avoid serious withdrawal symptoms, increased pain or psychological distress. See below for tips on tapering.

Note changes to prescribing information

The U.S. Food and Drug Administration (FDA) requires changes to prescribing information for opioids used in the outpatient setting. These changes will provide expanded guidance to health care providers on how to safely decrease the dose in patients who are physically dependent on opioid pain medicines.

Know why to taper

Reports of serious harm in patients who are physically dependent on opioid pain medicines, but who stop or decrease dosage quickly, include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.

An abrupt stop can lead to uncontrolled pain or withdrawal symptoms. In turn, these can lead patients to seek other sources of opioid pain medicines. The patient’s behavior may look like they are seeking drugs for abuse. Patients may attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substances.

Know how to taper

In general, for physically dependent patients, taper as follows:

Increment

Duration

Taper no more than 10–25%

Every 2 to 4 weeks

You may need to provide the patient with lower dosage strengths to successfully taper. If the patient experiences increased pain or serious withdrawal, you may need to pause the taper for a period of time, raise the dose to the prior dose, and then once stable, proceed with a more gradual taper.

Keep these tips in mind

These tips can help you and your patients stop or taper common opioids, such as codeine, fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, and oxymorphone.

  • Don't stop opioids for physically dependent patients. Counsel them not to stop suddenly. Talk about the need for slowly tapering.
  • Make sure you and the patient have an ongoing plan and agree on an appropriate tapering schedule, as well as a follow-up plan. Have clear and realistic patient and provider goals and expectations.
  • Create a patient-specific plan to slowly taper, as no plan fits all.
  • When managing patients taking opioids, especially those who have been treated for a long time and/or with high doses for chronic pain, ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to tapering. A multimodal approach to pain management may be best for treating chronic pain and tapering.
  • Patients who have been taking opioids for shorter time periods may tolerate a more rapid taper.
  • Frequent follow-up with patients is important. Reassess the patient regularly to manage pain and withdrawal symptoms that emerge. Common withdrawal symptoms include:
  • Restlessness
  • Lacrimation
  • Rhinorrhea
  • Yawning
  • Perspiration
  • Chills
  • Myalgia
  • Mydriasis
  • Other symptoms also may develop, including:
  • Irritability
  • Insomnia
  • Joint pain
  • Weakness
  • Anorexia
  • Vomiting
  • Increased heart rate
  • Anxiety
  • Backache
  • Increased blood pressure
  • Nausea
  • Diarrhea
  • Increased respiratory rate
  • Monitor patients for suicidal thoughts, use of other substances or changes in mood.
  • When stopping opioids due to a suspected substance use disorder, evaluate and treat the patient, or refer for evaluation and treatment of the substance use disorder. Treatment should include evidence-based approaches such as medication assisted treatment (MAT) of opioid use disorder. Referral to a specialist may help complex patients with comorbid pain and substance use disorders.

Prescribe naloxone

Prevent overdoses for patients taking long-term or high-dose opioids. Refer to the formularies and drug lists on the provider portal for coverage information. Within the context of the opioid epidemic, in California, AB 2760 may require prescribers to offer naloxone to patients when one or more of the following conditions are present:

  • The prescription dosage for the patient is 90 or more morphine milligram equivalents of an opioid medication per day.
  • An opioid medication is prescribed concurrently with a prescription for benzodiazepine.
  • The patient presents with an increased risk for overdose, including:

o A patient with a history of overdose; or

o A patient with a history of substance use disorder; or

o A patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant.

Consistent with the existing standard of care, physicians must provide education to patients receiving a prescription under this law on overdose prevention and the use of naloxone hydrochloride or another drug approved by the FDA for the complete or partial reversal of opioid depression. This education must also be offered to one or more persons designated by the patient, or, for a patient who is a minor, to the minor’s parent or guardian.

Tell members about myStrength

myStrength is an evidence-based, behavioral health self-help resource. It offers interactive, individually-tailored applications that empower members to address depression, anxiety, stress, substance use, chronic pain, and sleep challenges.

Members can access myStrength online at bh.mystrength.com/cahealthwellness.

Buprenorphine waiver training programs

You can take courses to get a waiver to prescribe buprenorphine. To learn more, visit samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training.

You can find information about more trainings by visiting the Providers’ Clinical Support System’s calendar of events at pcssnow.org/calendar-of-events.

Additional information

Providers are encouraged to access California Health & Wellness Plan’s (CHWP’s) provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.