Tapering Polypharmacy Regimens

Polypharmacy is a term used to describe a situation when a patient is prescribed multiple drugs. The term is frequently used to mean the use of too many or redundant drugs that can hinder function, delay return to work and dramatically increase workers’ compensation pharmacy costs.

Prescription drugs can become inappropriate over time due to the patient’s condition changing, a better drug or non-drug therapy becoming available, or the medication’s side effects outweighing its benefits. For example, long-term use of opioids can cause issues like constipation, sleep disorders, hyperalgesia, atrophy and dry mouth, requiring additional drugs to manage these symptoms. The additional drugs can cause more side effects and symptoms that may create a need for even more drugs.

Treatment for patients in chronic pain often evolves into a mixture of opioids, NSAIDs, benzodiazepines, muscle relaxants and antidepressants. Over time, a simple drug regimen with a single opioid can expand into five, eight, 12 or more drugs in multiple classifications.

To increase function, patients often need to be tapered, not just from a single drug or classification but from multiples of each. Unfortunately, there is little clinical support available to physicians who want to manage a tapering process, according to PRIUM’s white paper, “An Analysis of Drug Therapy Tapering Guidelines.”

Drugs in different classifications have different tapering protocols. While some medications, such as Celebrex, don’t require a gradual decline in dosage and can be discontinued fairly quickly, others cannot. Opioids like Oxycontin and benzodiazepines like Xanax require careful tapering, which is even more complicated when they are taken with other medications in multiple drug classifications.

Tapering Regimens

Decisions need to be made about what medication to reduce first, how it should be reduced, the duration for tapering and whether drugs can be reduced concurrently.

PRIUM examined 257 medical guidelines containing keywords such as “opioids” and “chronic pain” and applied filtering criteria like updates since 2009 and systemic review of medical literature. It found 18 guidelines that discussed initiating and maintaining opioid therapy. Only seven of the 18 discussed discontinuing opioid therapy, and those focused exclusively on tapering individual drug classifications, with no information on the duration of tapering.

Amazingly, none of the clinical guidelines addressed tapering opioids in a polypharmacy environment.

The white paper also found that 13 of the 18 opioid guidelines address psychosocial issues, which can play a major role in the proper management of chronic pain. Perceived injustice, fear avoidance and low self-esteem contribute to both pain and drug abuse. Other potential complications include personal discipline, depression, anxiety and enabling environments at home. If not identified and addressed, these conditions can sabotage the tapering process and result in relapse.

Finding the most effective tools to facilitate an individual’s ability to manage pain should be a major component of the tapering process – e.g., cognitive behavioral therapy or psychotherapy, exercise and stretching to relieve musculoskeletal pain, proper nutrition and good sleep habits.

Addressing psychosocial issues and helping patients develop coping skills costs much less than years of an inappropriate drug regimen. A multidisciplinary approach of medical and psychological treatment with physical fitness can equip patients to manage pain and lead functional, productive lives.