Gepubliceerd in The Lancet Public Health, januari 2020
- Peter C. Groot
- Jim van Os
In The Lancet Public Health, Gerard Kalkman and colleagues have made a much-needed inventory of the rising number of opioid prescription medication users in the Netherlands.1 We fully agree with their call for the implementation of safe opioid prescribing guidelines. However, improved and reduced prescribing of opioid painkillers can only solve part of the problem, because these measures will not help patients who are already using opioids and are struggling to come off them.
On April 9, 2019, the US Food and Drugs Administration (FDA) announced that it will require label changes to guide prescribers on gradual, individualised tapering of opioid pain medicines because forced discontinuation of opioids can result in uncontrolled pain, serious withdrawal symptoms, psychological distress, and suicide.2 Health-care professionals, the FDA warns, should not abruptly discontinue opioids in a patient who is physically dependent. Because no standard opioid tapering schedule exists that is suitable for all patients, health-care professionals should create a patient-specific plan to gradually taper the dose of the opioid and ensure ongoing monitoring and support, to avoid serious withdrawal symptoms, worsening of the patient’s pain, or psychological distress. The FDA says nothing about the pace or speed of tapering, but in a recent perspective,3 Dowell and colleagues note that for patients exposed to high dosages for years, slow tapers—eg, 10% reduction per month—might be needed, and that successful withdrawal could require months or years. The pace of tapering should be individualised.3
The important question we need to ask is can gradual tapering be made practically viable so that this good advice can be followed? In the Netherlands, we have addressed this issue specifically by developing so-called tapering strips, which allow a doctor to prescribe personalised, gradual tapering schedules using a shared decision-making approach.4, 5 The results of the first observational study of the use of tapering strips showed how successful such an approach can be, with 71% of patients who wished to discontinue an antidepressant succeeding in tapering completely, many of whom had previously failed one or more times to withdraw using other methods.5
We declare no competing interests.
Open AccessPublished: January, 2020
- Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study. Kalkman GA, Kramers C, van Dongen RT, van den Brink W, Schellekens A. Lancet Public Health. 2019; 4: e498-e505
- FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. FDA Drug Safety Communication. Date: April 9, 2019. Date accessed: September 24, 2019. https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes
- No shortcuts to safer opioid prescribing. Dowell D, Haegerich T, Chou R. N Engl J Med. 2019; 380: 2285-2287
- Tapering strips for paroxetine and venlafaxine. Tijdschr Psychiatrie. 2013; 55 (in Dutch).: 789-794
- Antidepressant tapering strips to help people come off medication more safely. Psychosis. 2018; 10: 142-145