Tackling rising numbers of opioid prescriptions users
Authors: Peter C Groot, Jim van Os
Journal: The Lancet Public Health (2020)

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.1Kalkman GA Kramers C van Dongen RT van den Brink W Schellekens A Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study.Lancet Public Health. 2019; 4: e498-e505Summary Full Text Full Text PDF PubMed Scopus (91) Google Scholar 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.2FDA Drug Safety CommunicationFDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changesDate: April 9, 2019Date accessed: September 24, 2019Google Scholar 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,3Dowell D Haegerich T Chou R No shortcuts to safer opioid prescribing.N Engl J Med. 2019; 380: 2285-2287Crossref PubMed Scopus (224) Google Scholar 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.3Dowell D Haegerich T Chou R No shortcuts to safer opioid prescribing.N Engl J Med. 2019; 380: 2285-2287Crossref PubMed Scopus (224) Google Scholar 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.4Groot PC Tapering strips for paroxetine and venlafaxine.Tijdschr Psychiatri. 2013; 55 (in Dutch).: 789-794PubMed Google Scholar, 5Groot PC van Os J Antidepressant tapering strips to help people come off medication more safely.Psychosis. 2018; 10: 142-145Crossref Scopus (24) Google Scholar 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.5Groot PC van Os J Antidepressant tapering strips to help people come off medication more safely.Psychosis. 2018; 10: 142-145Crossref Scopus (24) Google Scholar We declare no competing interests. Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database studyPrescription opioid use increased substantially between 2008 and 2017, and several proxies for misuse show a parallel increasing trend. Although the Netherlands is far from the opioid epidemic faced by the USA, safe opioid prescribing guidelines should be implemented to prevent further escalation and to keep opioid painkillers available for those in need. Full-Text PDF Open AccessTackling rising numbers of opioid prescriptions usersWe thank Peter Groot and Jim van Os for their comments1 on our Article.2 We agree with Groot and van Os that the implementation of safe prescribing guidelines will only curb the increase in chronic prescription opioid use, while offering no solution for patients currently using opioids who wish to discontinue.1 Since there were more than 200 000 chronic opioid users in the Netherlands in 2017,3 guidelines on how to effectively discontinue chronic opioid use are needed. Full-Text PDF Open Access