Tapering Controlled Substances Safely Abdullahi Mubarak, mD Associate Clinical Professor Wright state Univ. Addiction Medicine (ASAM)

Objectives Understanding the general principles of tapering controlled substances Understand the general objectives of medication tapering Understand the particular tapering of opioid and benzodiazepine medications

Tapering Considerations What was the diagnosis of the original condition for which the drug was prescribed? Is the diagnostic condition in remission or improved? Has the goal of treatment been realized? Will the patient have functional deterioration if the medication is tapered? Will alterative treatments prevent functional deterioration if the drug is tapered? Is the patient ready for a trial of medication tapering? Is there another diagnostic condition that necessitates medication tapering?

Lack of diagnosis Tisamarie Sherry, MD, PhD and associates (RAND Corporation) reported a paper published in Annals of Int. Med. (Sept. 2018) Retrospective review from data (2006-2015) from National Medical Care Survey Medical visits age 18 and older for which opioids were prescribed Visits were coded according to having a pain diagnosis (included >200 causes of pain and all diagnosis of diabetes (ICD-9) 5.1% of the patients had cancer-related pain diagnoses 66.4% of the patients had non-cancer pain diagnoses 28.5% of the patient had NO pain diagnosis

Is the diagnosis low back pain or neck pain or… Lumbar or cervical spinal stenosis Lumbar or cervical spondylosis Lumbar spondylolisthesis Ankylosing spondylitis Lumbar or cervical diskitits Rheumatoid or osteoarthritis Lumbar or cervical disc protrusion with nerve root compression Lumbar or cervical muscle sprain/strain Primary fibromyalgia syndrome

Is the diagnosis “Anxiety—NOS” or… Social anxiety disorder Generalized anxiety disorder Obsessive compulsive disorder Post-traumatic stress disorder Panic disorder with or without agoraphobia Adjustment reaction with mixed emotional or anxious features Major depression with anxious features Bipolar disorder Schizoaffective disorder Grief reaction

Obstacles to Diagnosis Patient obstacles include purposeful deception, poor memory, lack of descriptive vocabulary, cognitive impairments Provider obstacles include fear of being deceived, fear of regulatory agencies (DEA, Medical Board), fear of getting behind, lack of knowledge of differential diagnosis, poor record details from the prior prescriber, prescribing for symptoms (anxiety, low back pain) instead of diagnoses

The “Five A’s in pain management (Executive Committee of the Federation of State Medical Boards of the United States, Inc. Model policy on the use of opioid analgesics in the treatment of chronic pain. July 2013) Analgesia—Has there been a meaningful (>30% reduction) in pain? Activities of daily living—Has there been improvement in activities of daily living consistent with the patient’s goals? If so, what are they in particular (document)? Adverse affects—Are there any adverse affects from the medication prescribed? If so, are they or have they been modified (nausea, sedation, constipation, dry mouth, erectile dysfunction, cognitive impairment, repeated falls, hyperalgesia)? Aberrancy—repeated lost, stolen, or spilled prescriptions, illicit drug use, unsanctioned dose escalation (clinical deterioration, pseudo-addiction syndrome, tolerance, addiction), selling or forging prescriptions, stealing or borrowing medication Affect—Has the medication changed the patient’s mood for the better or worse?

Proposed adaptation of the “5 A’s” to benzodiazepine prescribing Anxiety—Has there been a “meaningful” in anxiety? Activities of daily living—Has there been improvement in activities of daily living consistent with the patient’s goals? If so, what are they in particular (document)? Adverse affects—Are there any adverse affects from the medication prescribed? If so, are they or have they been modified (sedation, dry mouth, repeated falls, cognitive impairment)? Aberrancy—repeated lost, stolen, or spilled prescriptions, illicit drug use, unsanctioned dose escalation (clinical deterioration, pseudo-addiction syndrome, tolerance, addiction), selling or forging prescriptions, stealing or borrowing medication Affect—Has the medication changed the patient’s mood for the better or worse?

Proposed adaptation of the “5 A’s” to Stimulant prescribing for ADD Attention—Has there been a meaningful reduction in lack of focus and inattentiveness? Activities of daily living—Has there been improvement in activities of daily living consistent with the patient’s goals? If so, what are they in particular (document)? Adverse affects—Are there any adverse affects from the medication prescribed? If so, are they or have they been modified (elevated BP, agitation, weight loss, dry mouth, erectile dysfunction, cognitive impairment)? Aberrancy—repeated lost, stolen, or spilled prescriptions, illicit drug use, unsanctioned dose escalation (clinical deterioration, pseudo-addiction syndrome, tolerance, addiction), selling or forging prescriptions, stealing or borrowing medication Affect—Has the medication changed the patient’s mood for the better or worse?

Indications for tapering The diagnosis is in remission or resolved Opiate-induced hyperalgesia Improvement with alternate treatments (CBT, interventional pain management, SSRI’s, SNRI’s etc…) Adverse drug-drug interactions No history of major drug withdrawal (delirium tremens, hallucinations, seizures) Dose of benzodiazepine is less than the maximum PDR recommended dose Medication adverse effects indicate risks are greater than the benefit Comorbidities are increasing the risk of complication Patient requested reduction

Indications For specialty referral History of complicated withdrawal (seizures, delirium tremens, hallucination) Patients with a history of alcohol or other substance use disorder Patients with illicit drug screening Concurrent severe medical or psychiatric disorder On benzodiazepines greater than the recommended PDR dose range

General “Rule of thumb” under age 65 Usual taper—10% of the original dose per week (approximately 3 month taper) Slower taper—3-5% of the original dose per week (approximately 6-12 months) If patient is having problems with taper due to fluctuation of blood levels of short-acting drugs, convert the original drug to a long-acting drug (Valium-20- 80 hour half-life). Advantage of Valium also includes multiple dose tablets (2mg, 5mg, 10mg) Taper off with consistent with the goals of treatment or taper to the lowest effective dose

Benzodiazepine conversion to diazepam 5mg Alprazolam (Xanax)--0.25 to 0.5mg Clonazepam (Klonopin)--0.25 to 0.5mg Lorazepam (Ativan)—0.5 to 1mg Temazepam (Restoril, Dalmane)—10mg Triazolam (Halcion)—0.25mg Chlordiazepoxide (Librium)—15mg Oxazepam (Serax)—10mg Chlorazepate (Tranxene)—7.5mg

General “Rule of thumb” age 65 and over Do not convert to diazepam if not already on it (increased reports of delirium) Convert to oxazepam or lorazepam (due to liver metabolism by conjugation) Substitute lorazepam for the current benzodiazepine one dose at a time every 3-7 days starting at night time dose (avoid drowsiness) until complete substituted. Dose lorazepam BID schedule and then3-5% per week reduction (“rule of thumb”). Lorazepam dose advantages available as 0.5mg, 1mg, 2mg and 2mg/ml solution