Opioid Stewardship: How OAT Can Be a Tool for Deprescribing

Blog / By

TL;DR:

  • Family physicians often manage patients on high-dose or complex chronic opioid regimens who wish to reduce their dose but are unable to due to dependence and withdrawal.
  • Attempting to rapidly taper these patients is often unsuccessful and can destabilize them, increasing their risk of turning to the illicit market.
  • Transitioning a patient from their short-acting opioid regimen to a long-acting OAT medication like methadone or buprenorphine is a highly effective, evidence-based deprescribing strategy.
  • This “lateral transfer” simplifies the regimen, eliminates the peaks and troughs of short-acting opioids, and moves the prescribing to a specialized clinic like Arrow Medical, supporting your opioid stewardship goals.

Table of Contents

  1. The Primary Care Challenge: The Complex Chronic Opioid Patient
  2. Why Tapering Often Fails (and The Risks of Failure)
  3. OAT as a Deprescribing Strategy: A “Lateral Transfer”
  4. The Benefits for the Patient and the Primary Care Provider
  5. How to Make the Referral to Arrow Medical

As a family physician, you may have patients who have been on chronic opioid therapy for years, often for chronic non-cancer pain. You may have inherited these patients, or their opioid requirements may have escalated over time. Now, you find yourself in a difficult clinical situation:

  • The patient may be on high doses of multiple short-acting opioids.
  • They may be exhibiting signs of an Opioid Use Disorder (OUD), such as running out of their prescription early or “pill-watching.”
  • Both you and the patient may want to reduce their opioid burden, but every attempt at tapering fails due to severe withdrawal symptoms.

This is a common and stressful scenario. You want to practice good opioid stewardship, but you also don’t want to abandon your patient or precipitate a crisis. There is an effective and compassionate solution: using Opioid Agonist Treatment (OAT) as a deprescribing tool.

Why Tapering Often Fails (and The Risks of Failure)

For a patient who has developed significant physiological dependence, a forced or rapid taper of their opioids is often intolerable. The withdrawal symptoms are severe, and their pain may feel unmanageable.

The risks of a failed taper are significant:

  1. Destabilization: The patient’s physical and mental health can decline.
  2. Erosion of Trust: The doctor-patient relationship can be damaged.
  3. Diversion to the Illicit Market: This is the greatest risk. A patient with high opioid tolerance who is cut off from their prescription is at extremely high risk of turning to the dangerous, fentanyl-contaminated street supply to manage their withdrawal.

OAT as a Deprescribing Strategy: A “Lateral Transfer”

Instead of a difficult vertical taper, a safer and more effective strategy is a “lateral transfer.” This involves transitioning the patient from their complex regimen of short-acting opioids to a single, once-daily dose of a long-acting OAT medication.

OAT as Deprescribing: The process of converting a patient from a regimen of short-acting opioids (e.g., hydromorphone, oxycodone) to a stable, once-daily dose of a long-acting opioid agonist (methadone or buprenorphine) under the care of a specialized addiction clinic.

How it Works:

  • You refer the patient to a clinic like Arrow Medical.
  • Our physicians will conduct an assessment and start the patient on methadone or buprenorphine.
  • We will carefully titrate their OAT dose until it effectively manages their withdrawal and cravings, allowing them to stop their other opioids.
  • The result is a simplified, more stable regimen managed by specialists.
  • The patient can either be sent back to yourself for ongoing management of their OAT, or continued to be followed at an OAT clinic like Arrow Medical

This isn’t about starting a new opioid; it’s about replacing a chaotic regimen with a structured, stable one. It is a fundamental deprescribing strategy.

The Benefits for the Patient and the Primary Care Provider

This approach offers significant benefits for everyone involved.

For the Patient:

  • Eliminates “Pill-Watching”: The long-acting nature of OAT smooths out the peaks and troughs, ending the cycle of watching the clock for the next dose.
  • Reduces Cravings: It effectively manages the cravings that are often a part of long-term opioid use.
  • Provides Stability: It allows them to stabilize their life without the distress of a painful taper.

For the Primary Care Provider:

  • Achieves Deprescribing Goals: You successfully and safely reduce the patient’s reliance on short-acting opioids.
  • Reduces Clinical Burden and Risk: The prescribing and monitoring of the opioid is transferred to a specialized clinic.
  • Provides Comprehensive Support: You can be confident your patient is receiving expert, wrap-around care for their OUD, allowing you to focus on their other primary care needs.

How to Make the Referral to Arrow Medical

Making this transition is simple with our walk-in model.

  1. Have a Conversation: Talk to your patient about this as a positive strategy to help them feel better and more stable. Frame it as a referral to a specialist, just like you would for a cardiologist.
  2. Make a Warm Hand-off: Our model requires no formal referral forms. You can simply provide your patient with our clinic information and instruct them to walk in. A phone call to our clinic to provide context is always welcome but not required.

You don’t have to manage complex chronic opioid therapy alone. By partnering with Arrow Medical, you can use OAT as a powerful deprescribing tool that is safer for your patients and supportive of your practice. Let us be your partners in opioid stewardship.

Related Posts