Opioid abuse/misuse is a serious problem in the United States. In response to this issue, some patients are attempting to stop taking opioids, and health care providers are discontinuing many of their patients' opioid prescriptions. For many patients, however, long-term use of opioids has resulted in a physical dependence on these drugs.

According to the Substance Abuse and Mental Health Services Administration, physical dependence on opioids begins after about two weeks of daily use. Physical dependence is not the same as addiction, although some symptoms can overlap. Addiction is compulsive drug use despite harmful consequences that can affect an individual's health, work, and personal relationships. Dependence is when the body has become accustomed to the drug and a larger dose is required to achieve the same effect (in other words, tolerance). Because the body has physically adapted to the drug, physical and mental changes occur when the drug is abruptly stopped. Serious withdrawal symptoms include hypertension, tachycardia, tachypnea, anxiety, irritability, insomnia, and myalgia. Mood changes, including suicidality, can also occur with withdrawal. Physical dependence and withdrawal do not indicate addiction, even though withdrawal symptoms can occur in addiction.

Patients who are physically dependent on opioids and who suddenly stop taking the drugs, or whose health care provider stops or drastically reduces the dose too quickly, will likely experience significant withdrawal symptoms. Patients treated for chronic pain can also experience severe, uncontrolled pain when their opioid is stopped suddenly. The experience of severe withdrawal symptoms and/or pain may cause patients to seek other opioid sources, both legal and illicit.

The Food and Drug Administration (FDA) has announced that it is requiring changes to the labeling of prescription opioids in order to guide health care providers in gradual, individualized tapering of drug doses. Commonly prescribed opioids receiving these label changes include codeine, fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, and oxymorphone. The FDA notes that there is not one universal tapering strategy: it's important to consider factors such as the dose of the drug, the duration of treatment, the pain being treated, and the patient's physical and psychological characteristics.

The FDA recommends that patients who are opioid dependent should have their dose tapered by 10% to 25% every two to four weeks. Patients who are experiencing significant pain or withdrawal symptoms may need to temporarily receive their previously prescribed dose to stabilize their symptoms. Once the patient is stabilized, the health care provider can slowly resume dose tapering. NPs should remember that patients with a suspected substance use disorder may need to be referred for evaluation and treatment to a practitioner who specializes in this condition. Nurses should advise patients not to suddenly stop taking their prescribed opioids but to gradually decrease the dose under the supervision of a health care provider.

To read the FDA Drug Safety Communication on the risks of suddenly discontinuing opioid treatment, see http://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-report.