This article, written by a group of researchers based at a large, urban, safety net primary care clinic that offers treatment with buprenorphine for those with opioid use disorder, highlights the real-world difficulties of tapering off treatment. The researchers did not create an intervention, but instead identified in their extensive database patients who had either requested a taper from their treatment provider or who had tapered on their own.
Increasing numbers of primary care providers have been obtaining their DATA 2000 waiver and offering treatment with buprenorphine typically in combination with naloxone in their office as part of their general practice. On occasion, patients will suggest tapering off medication in part because of convenience or stigma, although sometimes out of personal preferences and values. Treatment providers know that long-term, medication-assisted therapy reduces many adverse outcomes, including return to opioid abuse, overdose, criminal behavior, acquisition of hepatitis C and HIV, and others. Currently, the optimal duration of therapy is unknown and most patients prefer to stay in treatment and are typically treated long-term on a stable dose.
In addition, most PCPs who offer treatment for opioid use disorder struggle with accommodating as many patients as need treatment in their practice or community as PCPs are often in high demand for primary care services, as well. Thus, having a patient successfully taper creates an opening for an individual provider to take on new patients who need treatment.
Weinstein and colleagues describe a low number of patients who initiate a treatment taper, with the majority doing it on their own. Somewhat less than half did it under medical supervision and these patients were typically tapered much more slowly. Overall, most individuals were unable to complete their taper and stop medication. Of those who did, the majority went back on treatment, typically years later. While it is not known what happened to those patients in the interim, it is likely that most of them relapsed prior to re-engaging in treatment.
What can primary care providers take away from this article? First, few practitioners who are experienced in working with individuals suffering from opioid use disorder will be surprised. The vast majority of individuals prefer to stay on treatment and find it invaluable in maintaining their sobriety. Even if PCPs are not actively engaged in providing medication-assisted treatment, they should support their patients who are receiving this highly effective therapy and encourage them to feel good about maintaining treatment if it helps them to avoid relapse and the dangers of active opioid abuse.
PCPs who are providing treatment need to feel comfortable that this will be a long-term and possibly lifelong therapy for their patients. We can support those who are motivated to taper, though PCPs should always welcome them back into treatment and facilitate this process should it become necessary. Lastly, policymakers must recognize the need for a large primary care workforce to provide effective therapy for the millions of individuals currently suffering from opioid use disorder, as these individuals require frequent visits and many years of treatment.
Lawrence Greenblatt, MD
professor of medicine and community and family medicine, Duke University School of Medicine
Disclosures: Greenblatt reports no relevant financial disclosures.