Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study

Short- and long-term safety of discontinuing chronic opioid therapy among older adults with Alzheimer's disease and related dementia

BACKGROUND

Limited evidence exists on the short- and long-term safety of discontinuing versus continuing chronic opioid therapy (COT) among patients with Alzheimer's disease and related dementias (ADRD).

METHODS

This cohort study was conducted among 162,677 older residents with ADRD and receipt of COT using a 100% Medicare nursing home sample. Discontinuation of COT was defined as no opioid refills for ≥90 days. Primary outcomes were rates of pain-related hospitalisation, pain-related emergency department visit, injury, opioid use disorder (OUD) and opioid overdose (OD) measured by diagnosis codes at quarterly intervals during 1- and 2-year follow-ups. Poisson regression models were fit using generalised estimating equations with inverse probability of treatment weights to model quarterly outcome rates between residents who discontinued versus continued COT.

RESULTS

The study sample consisted of 218,040 resident episodes with COT; of these episodes, 180,916 residents (83%) continued COT, whereas 37,124 residents (17%) subsequently discontinued COT. Discontinuing (vs. continuing) COT was associated with higher rates of all outcomes in the first quarter, but these associations attenuated over time. The adjusted rates of injury, OUD and OD were 0, 69 and 60% lower at the 1-year follow-up and 11, 81 and 79% lower at the 2-year follow-up, respectively, for residents who discontinued versus continued COT, with no difference in the adjusted rates of pain-related hospitalisations or emergency department visits.

CONCLUSIONS

The rates of adverse outcomes were higher in the first quarter but lower or non-differential at 1-year and 2-year follow-ups between COT discontinuers versus continuers among older residents with ADRD.

Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study

BACKGROUND

Both increases and decreases in patients' prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined.

OBJECTIVE

To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days.

DESIGN

Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors.

PARTICIPANTS

All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients).

MAIN MEASURES

Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME).

KEY RESULTS

Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk.

CONCLUSIONS

Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.

Effectiveness of Long-Term Opioid Therapy for Chronic Pain in an Outpatient Palliative Medicine Clinic

Background: Despite widespread use of opioid therapy in outpatient palliative medicine, there is limited evidence supporting its efficacy and safety in the long term. Objectives: We sought to improve overdose risk scores, maintain pain reduction, and preserve patient function in a cohort with severe chronic pain as we managed opioid therapy for a duration of four years in an outpatient palliative care clinic. Design: Over four years, we provided ongoing goal-concordant outpatient palliative care, including opioid therapy, using quarterly clinical encounters for a patient cohort with chronic pain. Setting/Subjects: The project took place in the outpatient palliative medicine clinic of a regional cancer center in Orlando, Florida (United States). The subjects were a cohort group who received palliative care during the time period between July 2018 and October 2022. Measurements: Key metrics included treatment-related reduction in pain intensity, performance scores, and overall overdose risk scores. Secondary metrics included cohort demographics, average daily opioid use in morphine milligram equivalents and categorization of type of pain. Results: In 97 patients, we observed a stable mean treatment-related reduction in pain intensity of 4.9 out of 10 points over four years. The cohort showed a 2-point (out of 100) improvement in performance scores and an 81-point (out of 999) reduction in mean overall overdose risk score. Conclusions: We present evidence that providing outpatient palliative care longitudinally over four years offered lasting treatment-related reductions in pain intensity, preservation of performance status, and reduction in overall overdose risk.

A Pharmacist-Assisted Initiative to Improve Chronic Pain Management and Reduce Opioid Use in Primary Care

Background- Since publication of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, there have been growing concerns that providers, including those in primary care, are tapering opioids too quickly and without concomitant use of non-opioid strategies for pain, leading to inadequate pain management. As a result, in November 2022 the CDC published Clinical Practice Guidelines for Prescribing Opioids for Pain, emphasizing the importance of creating comprehensive care plans for pain management and developing a consensual plan between provider and patient when tapering opioids. Objective-Determine the impact of a pharmacist-assisted approach aimed at helping primary care providers minimize opioid use while improving management of chronic, non-malignant pain (CNMP). Methods - This quality improvement project focused on one primary care provider partnering with a pharmacist to reassess the management of patients on long-term opioid therapy (LTOT) for CNMP. The intervention included a letter informing patients of the provider's intent, pharmacist outreach to intervention patients, and pharmacist development of a patient registry, updated regularly with clinical data, recommendations, and outcomes for the provider to reference throughout the project. The intervention group was compared to patients prescribed opioids for CNMP by the remaining providers at the clinic who did not engage in the quality initiative. Results - The intervention group had a mean effective daily morphine milligram equivalent (MME) reduction of 73.7% (17.2% control) after 18 months and 60% of patients discontinued opioids (14.3% control). In a subset of patients with functional assessment scores, 93.3% were either improved or unchanged, despite a 62.5% decrease in their mean effective daily MME. In both groups, one patient transferred care to a new provider. Conclusions - With targeted recommendations and assistance from a pharmacist, a primary care provider can make significant progress in improving management of CNMP while reducing opioid prescribing.

The Analgesic Mismanagement of a Patient With Ehlers-Danlos Syndrome (Hypermobility Variant): A Case Report

Ehlers-Danlos syndrome (EDS) is a rare disorder affecting the connective tissue, resulting in joint hypermobility, elastic skin, and often chronic pain, especially in the hypermobility variant. Although opioids are commonly prescribed for pain, they can lead to opioid use disorder (OUD) and overdose. A 67-year-old female with Ehlers-Danlos syndrome hypermobility type (EDS-HT), osteoarthritis (OA), and anxiety received opioid-based pain management for a decade before changing her primary care physician. Her medications included oxycodone and morphine sulfate extended-release (ER) at different dosages. To lower overdose risk, her morphine milligram equivalents (MME) were tracked, and a step-by-step opioid tapering process was started. Diagnosing EDS is difficult due to symptom overlap with other connective tissue disorders. Chronic pain in EDS involves both nociceptive and neuropathic pain, necessitating a comprehensive pain management approach. The essential components of pain management include non-opioid medications, physical therapy, and psychological support. Opioids should be used cautiously in EDS patients because of connective tissue vulnerabilities and potential side effects. Personalized plans for opioid tapering may be appropriate for those on long-term opioid therapy. Managing EDS-related chronic pain requires a tailored, multidisciplinary approach. Early and accurate diagnosis and specialized healthcare providers familiar with EDS are crucial for effective pain management. Ongoing research and evidence-based pain management approaches are vital to address the unique needs of EDS patients, promoting better pain relief and overall well-being. Through meticulous evaluation and personalized treatment plans, healthcare professionals can better support EDS patients in managing chronic pain and reducing opioid dependence and misuse risks. A comprehensive approach, incorporating non-opioid medications, physical therapy, and psychological support, can offer effective pain relief and improve the quality of life for those living with EDS.

Impact of CYP2D6 genotype on opioid use disorder deprescription: an observational prospective study in chronic pain with sex-differences

Introduction: Opioid deprescription is the process of supervised tapering and safe withdrawal when a potentially inappropriate use is detected. This represents a challenge in chronic non-cancer pain (CNCP) patients who may respond differently to the procedure. Our aim was to analyze the potential impact of CYP2D6 phenotypes and sex on the clinical and safety outcomes during an opioid use disorder (OUD) tapering process. Methods: A prospective observational study was conducted on CNCP ambulatory OUD patients (cases, n = 138) who underwent a 6-month opioid dose reduction and discontinuation. Pain intensity, relief and quality of life (Visual analogue scale, VAS 0-100 mm), global activity (GAF, 0-100 scores), morphine equivalent daily dose (MEDD), analgesic drugs adverse events (AEs) and opioid withdrawal syndrome (OWS, 0-96 scores) were recorded at basal and final visits. Sex differences and CYP2D6 phenotypes (poor (PM), extensive (EM) and ultrarapid (UM) metabolizers based on CYP2D6*1, *2, *3, *4, *5, *6, *10, *17, *41, 2D6*5, 2D6 × N, 2D6*4 × 2 gene variants) were analyzed. Results: Although CYP2D6-UM consumed three-times less basal MEDD [40 (20-123) mg/day, p = 0.04], they showed the highest number of AEs [7 (6-11), p = 0.02] and opioid withdrawal symptoms (46 ± 10 scores, p = 0.01) after deprescription. This was inversely correlated with their quality of life (r = -0.604, p < 0.001). Sex-differences were evidenced with a tendency to a lower analgesic tolerability in females and lower quality of life in men. Discussion: These data support the potential benefits of CYP2D6-guided opioid deprescription, in patients with CNCP when OUD is detected. Further studies are required to understand a sex/gender interaction.

Shared Decision-Making in Acute Pain Services

PURPOSE OF REVIEW

The implementation of shared decision-making (SDM) in acute pain services (APS) is still in its infancies especially when compared to other medical fields.

RECENT FINDINGS

Emerging evidence fosters the value of SDM in various acute care settings. We provide an overview of general SDM practices and possible advantages of incorporating such concepts in APS, point out barriers to SDM in this setting, present common patient decisions aids developed for APS and discuss opportunities for further development. Especially in the APS setting, patient-centred care is a key component for optimal patient outcome. SDM could be included into everyday clinical practice by using structured approaches such as the "seek, help, assess, reach, evaluate" (SHARE) approach, the 3 "MAking Good decisions In Collaboration"(MAGIC) questions, the "Benefits, Risks, Alternatives and doing Nothing"(BRAN) tool or the "the multifocal approach to sharing in shared decision-making"(MAPPIN'SDM) as guidance for participatory decision-making. Such tools aid in the development of a patient-clinician relationship beyond discharge after immediate relief of acute pain has been accomplished. Research addressing patient decision aids and their impact on patient-reported outcomes regarding shared decision-making, organizational barriers and new developments such as remote shared decision-making is needed to advance participatory decision-making in acute pain services.

Association Between Opioid Tapering and Subsequent Health Care Use, Medication Adherence, and Chronic Condition Control

Importance

Opioid tapering has been associated with negative consequences, such as increased overdoses and mental health needs. Tapering could also alter use of health care services and worsen care of comorbid conditions through disruption in primary care.

Objective

To evaluate tapering of stable long-term opioid therapy (LTOT) and subsequent health care service use and chronic condition care.

Design, Setting, and Participants

A retrospective cohort study was conducted from January 1, 2008, to December 31, 2019. Data analysis was performed from July 9, 2020, to December 9, 2022. Data from the Optum Labs Data Warehouse, which contains deidentified retrospective administrative claims data and linked electronic health record data for commercial and Medicare Advantage enrollees, were used. Adults aged 18 years or older prescribed stable doses of LTOT at 50 morphine milligram equivalents or more per day during a 12-month baseline period were included, including subcohorts with hypertension or diabetes.

Exposures

Opioid tapering, with 15% or more relative reduction in mean daily dose in 6 overlapping periods during 6 months.

Main Outcomes and Measures

Emergency department visits, hospitalizations, primary care and specialist visits, antihypertensive or antiglycemic medication adherence, and blood pressure and hemoglobin A1c levels during up to 12 months' follow-up. Covariates included sociodemographic characteristics, comorbidities, health care use, and chronic condition control.

Results

Among 113 604 patients (60 764 [53.5%] women; mean [SD] age, 58.1 [11.8] years) prescribed LTOT, 41 207 had hypertension and 23 335 had diabetes; in all cohorts, approximately half were women, and half were aged 50 to 65 years. In the overall cohort, tapering was associated with more emergency department visits (adjusted incidence rate ratio [aIRR], 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR, 1.16; 95% CI, 1.12-1.20), with similar magnitude associations in the hypertension and diabetes subcohorts. Tapering was associated with fewer primary care visits in the overall cohort (aIRR, 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR, 0.98; 95% CI, 0.97-0.99). For the hypertension or diabetes subcohorts, tapering was associated with reduced medication adherence (hypertension: aIRR, 0.60; 95% CI, 0.59-0.62; diabetes: aIRR, 0.69; 95% CI, 0.67-0.71) and small increases in diastolic blood pressure and hemoglobin A1c level.

Conclusions and Relevance

In this cohort study of patients prescribed LTOT, opioid tapering was associated with more emergency department visits and hospitalizations, fewer primary care visits, and reduced antihypertensive and antidiabetic medication adherence. These outcomes may represent unintended negative consequences of opioid tapering for policy makers and clinicians to consider.

Intended and unintended consequences: Changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - Controlled and single-series interrupted time series analyses

BACKGROUND

The potential misapplication of current opioid prescribing policies remains understudied and may have substantial adverse implications for patient safety.

METHODS

We used autoregressive integrated moving average models to assess level and trend changes in monthly 1) prescribing rates, 2) days' supply, and 3) daily morphine milligram equivalents (MME) of incident opioid prescriptions relative to 1) a state medical board initiative to reduce high-dose and -volume opioid prescribing and 2) legislation to limit initial opioid prescriptions for acute and postsurgical pain. We examined outcomes by pain indication overall and by cancer history, using prescribing patterns for benzodiazepines to control for temporal trends. We used large private health insurance claims data to include North Carolina residents, aged 18-64, insured at any point between January 2012 and August 2018.

RESULTS

After the medical board initiative, prescribing patterns for chronic pain patients did not change; conversely, acute and postsurgical pain patients experienced immediate declines in daily MME. Post-legislation prescription rates did not decline for those with acute, postsurgical, and non-cancer pain, but instead declined among cancer patients with chronic pain. Chronic pain patients experienced the largest days' supply declines post-legislation, instead of acute and postsurgical pain patients.

CONCLUSIONS

We found mixed evidence on the potential impact of two opioid prescribing policies, with some observed declines in a group not intended to be impacted by the policy. This study provides evidence of the need for clearer opioid prescribing policies to ensure impacts on intended populations and avoid unintended consequences.

Medication Use Evaluation of High-Dose Long-Term Opioid De-prescribing in Multiple Veterans Affairs Medical Centers

BACKGROUND

The Opioid Safety Initiative (OSI) was implemented in 2013 to enhance the safe and appropriate use of opioids in the Veterans Health Administration (VA). Opioid use decreased nationally in subsequent years, but characterization of opioid de-prescribing practices has not been well established.

OBJECTIVES

To describe changes in patient characteristics and patterns of de-prescribing since OSI implementation for opioid users at > 90 morphine equivalent daily dose for at least 90 days for those that discontinued opioids within the VA.

DESIGN

Retrospective observational pre-post intervention medication use evaluation using VA data and electronic health records to identify differences in opioid de-prescribing between fiscal year 2013 (FY13; early OSI) and FY17 (late OSI). Reviewers' insights for local opioid management and de-prescribing practices collected through web-based post-data collection survey.

PARTICIPANTS

Veterans prescribed high-dose long-term opioid therapy in FY13 and FY17 who subsequently discontinued opioids at 27 VA medical centers.

MAIN MEASURES

Chart review data from local facility reviewers identified socioeconomic characteristics, opioid de-prescribing rationale (e.g., risk-benefit, diversion) and practices (e.g., rate of opioid discontinuation, taper monitoring activities, withdrawal monitoring), and outcomes following discontinuation.

KEY RESULTS

Among 315 patients in FY13 and 322 patients in FY17 with opioid discontinuation, discontinuation rationale focused on diversion in FY13 and risk-benefit in FY17. Clinical pharmacists and pain management specialists had increased involvement in FY17 opioid discontinuations (36% versus 16%). Of all discontinuations, 56% of patients were tapered in FY13 versus 70% of patients in FY17. Tapering plans were longer in FY17 than in FY13 (163 days versus 65 days). Transitions to non-opioid pain therapy following opioid discontinuation were higher in FY17 compared to FY13 (70% versus 60%).

CONCLUSIONS

Veterans discontinued from high-dose long-term opioids in FY17 were more optimally managed compared to those in FY13. Findings suggest improvements in opioid de-prescribing following OSI implementation, but interpretation is limited by study design.

Discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain with and without opioid use disorder in British Columbia, Canada: A retrospective cohort study

BACKGROUND

The overdose crisis in North America has prompted system-level efforts to restrict opioid prescribing for chronic pain. However, little is known about how discontinuing or tapering prescribed opioids for chronic pain shapes overdose risk, including possible differential effects among people with and without concurrent opioid use disorder (OUD). We examined associations between discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain, stratified by diagnosed OUD and prescribed opioid agonist therapy (OAT) status.

METHODS AND FINDINGS

For this retrospective cohort study, we used a 20% random sample of residents in the provincial health insurance client roster in British Columbia (BC), Canada, contained in the BC Provincial Overdose Cohort. The study sample included persons aged 14 to 74 years on long-term opioid therapy for pain (≥90 days with ≥90% of days on therapy) between October 2014 and June 2018 (n = 14,037). At baseline, 7,256 (51.7%) persons were female, the median age was 55 years (quartile 1-3: 47-63), 227 (1.6%) persons had been diagnosed with OUD (in the past 3 years) and recently (i.e., in the past 90 days) been prescribed OAT, and 483 (3.4%) had been diagnosed with OUD but not recently prescribed OAT. The median follow-up duration per person was 3.7 years (quartile 1-3: 2.6-4.0). Marginal structural Cox regression with inverse probability of treatment weighting (IPTW) was used to estimate the effect of prescribed opioid treatment for pain status (discontinuation versus tapered therapy versus continued therapy [reference]) on risk of overdose (fatal or nonfatal), stratified by the following groups: people without diagnosed OUD, people with diagnosed OUD receiving OAT, and people with diagnosed OUD not receiving OAT. In marginal structural models with IPTW adjusted for a range of demographic, prescription, comorbidity, and social-structural exposures, discontinuing opioids (i.e., ≥7-day gap[s] in therapy) was associated with increased overdose risk among people without OUD (adjusted hazard ratio [AHR] = 1.44; 95% confidence interval [CI] 1.12, 1.83; p = 0.004), people with OUD not receiving OAT (AHR = 3.18; 95% CI 1.87, 5.40; p < 0.001), and people with OUD receiving OAT (AHR = 2.52; 95% CI 1.68, 3.78; p < 0.001). Opioid tapering (i.e., ≥2 sequential decreases of ≥5% in average daily morphine milligram equivalents) was associated with decreased overdose risk among people with OUD not receiving OAT (AHR = 0.31; 95% CI 0.14, 0.67; p = 0.003). The main study limitations are that the outcome measure did not capture overdose events that did not result in a healthcare encounter or death, medication dispensation may not reflect medication adherence, residual confounding may have influenced findings, and findings may not be generalizable to persons on opioid therapy in other settings.

CONCLUSIONS

Discontinuing prescribed opioids was associated with increased overdose risk, particularly among people with OUD. Prescribed opioid tapering was associated with reduced overdose risk among people with OUD not receiving OAT. These findings highlight the need to avoid abrupt discontinuation of opioids for pain. Enhanced guidance is needed to support prescribers in implementing opioid therapy tapering strategies with consideration of OUD and OAT status.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment

IMPORTANCE

Uncertainty remains about the longer-term benefits and harms of different opioid management strategies, such as tapering and dose escalation. For instance, opioid tapering could help patients reduce opioid exposure to prevent opioid use disorder, but patients may also seek care elsewhere and engage in nonprescribed opioid use.

OBJECTIVE

To evaluate the association between opioid dose trajectories observed in practice and patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted in 3 health systems in Colorado and Wisconsin. The study population included patients receiving long-term opioid therapy between 50 and 200 morphine milligram equivalents between August 1, 2014, and July 31, 2017. Follow-up ended on December 31, 2019. Data were analyzed from January 2020 to August 2022.

EXPOSURES

Group-based trajectory modeling identified 5 dosing trajectories over 1 year: 1 decreasing, 1 high-dose increasing, and 3 stable.

MAIN OUTCOMES AND MEASURES

Primary outcomes assessed after the trajectory period were 1-year all-cause mortality, incident opioid use disorder, continued opioid therapy at 1 year, and health plan disenrollment. Associations were tested using Cox proportional hazards regression and log-binomial models, adjusting for baseline covariates.

RESULTS

A total of 3913 patients (mean [SD] age, 59.2 [14.4] years; 2767 White non-Hispanic [70.7%]; 2237 female patients [57.2%]) were included in the study. Compared with stable trajectories, the decreasing dose trajectory was negatively associated with opioid use disorder (adjusted hazard ratio [aHR], 0.40; 95% CI, 0.29-0.55) and continued opioid therapy (site 1: adjusted relative risk [aRR], 0.39; 95% CI, 0.34-0.44), but was positively associated with health plan disenrollment (aHR, 1.66; 95% CI, 1.24-2.22). The decreasing trajectory was not associated with mortality (aHR, 1.28; 95% CI, 0.87-1.86). In contrast, the high-dose increasing trajectory was positively associated with mortality (aHR, 2.19; 95% CI, 1.44-3.32) and opioid use disorder (aHR, 1.81; 95% CI, 1.39-2.37) but was not associated with disenrollment (aHR, 0.90; 95% CI, 0.56-1.42) or continued opioid therapy (site 1: aRR, 0.98; 95% CI, 0.94-1.03).

CONCLUSIONS AND RELEVANCE

In this cohort study, decreasing opioid dose was associated with reduced risk of opioid use disorder and continued opioid therapy but increased risk of disenrollment compared with stable dosing, whereas the high-dose increasing trajectory was associated with an increased risk of mortality and opioid use disorder. These findings can inform opioid management decision-making.

Validation and endorsement of health system performance measures for opioid use disorder in British Columbia, Canada: A Delphi panel study

Background

Limited data exists on the performance of the healthcare system in opioid use disorder (OUD). We evaluated the face validity and potential risks of a set of health system performance measures for OUD collaboratively with clinicians, policymakers and people with lived experience of opioid use (PWLE) in the interest of establishing an endorsed set of measures for public reporting.

Methods

Through a two-stage Delphi-panel approach, a panel of clinical and policy experts validated and considered 102 previously constructed OUD performance measures for endorsement using information on measurement construction, sensitivity analyses, quality of evidence, predictive validity, and feedback from local PWLE. We collected quantitative and qualitative survey responses from 49 clinicians and policymakers, and 11 PWLE. We conducted inductive and deductive thematic analysis to present qualitative responses.

Results

A total of 37 measures of 102 were strongly endorsed (9/13 cascade of care, 2/27 clinical guideline compliance, 17/44 healthcare integration, and 9/18 healthcare utilization measures). Thematic analysis of responses revealed several themes regarding measurement validity, unintended consequences, and key contextual considerations. Overall, measures related to the cascade of care (excluding opioid agonist treatment dose tapering) received strong endorsements. PWLE highlighted barriers to accessing treatment, undignified aspects of treatment, and lack of a full continuum of care as their concerns.

Conclusion

We defined 37 endorsed health system performance measures for OUD and presented a range of perspectives on their validity and use. These measures provide critical considerations for health system improvement in the care of people with OUD.

Surgeon Variation in Perioperative Opioid Prescribing and Medium- or Long-term Opioid Utilization after Total Knee Arthroplasty: A Cross-sectional Analysis

BACKGROUND

Whether a particular surgeon's opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. This study tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively.

METHODS

The study identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011, and December 31, 2016. "High-intensity" surgeons were defined as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7). The study then estimated whether patients of high-intensity surgeons had higher opioid utilization in the midterm (postoperative days 8 to 90) and long-term (postoperative days 91 to 365), utilizing an instrumental variable approach to minimize confounding from unobservable factors.

RESULTS

In the final sample of 604,093 patients, the average age was 74 yr (SD 5), and there were 413,121 (68.4%) females. A total of 180,926 patients (30%) were treated by high-intensity surgeons. On average, patients receiving treatment from a high-intensity surgeon received 36.1 (SD 35.0) oral morphine equivalent (morphine milligram equivalents) per day during the immediate perioperative period compared to 17.3 morphine milligram equivalents (SD 23.1) per day for all other patients (+18.9 morphine milligram equivalents per day difference; 95% CI, 18.7 to 19.0; P < 0.001). After adjusting for confounders, receiving treatment from a high-intensity surgeon was associated with higher opioid utilization in the midterm opioid postoperative period (+2.4 morphine milligram equivalents per day difference; 95% CI, 1.7 to 3.2; P < 0.001 [11.4 morphine milligram equivalents per day vs. 9.0]) and lower opioid utilization in the long-term postoperative period (-1.0 morphine milligram equivalents per day difference; 95% CI, -1.4 to -0.6; P < 0.001 [2.8 morphine milligram equivalents per day vs. 3.8]). While statistically significant, these differences are clinically small.

CONCLUSIONS

Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods.

EDITOR’S PERSPECTIVE

Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering

IMPORTANCE

Patients prescribed long-term opioid therapy are increasingly undergoing dose tapering. Recent studies suggest that tapering is associated with short-term risks of substance misuse, overdose, and mental health crisis, although lower opioid dose could reduce risks of adverse events over the longer term.

OBJECTIVE

To assess the longer-term risks of overdose or mental health crisis associated with opioid dose tapering.

DESIGN, SETTING, AND PARTICIPANTS

This is a cohort study using an exposure-crossover analysis. Data were obtained from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims and enrollment records for commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities, and geographical regions across the US. Participants were US adults who underwent opioid dose tapering from 2008 to 2017 after a 12-month baseline period of stable daily dosing of 50 morphine milligram equivalents or higher and who had at least 1 month of long-term follow-up during a postinduction period beginning 12 months after taper initiation. Data analysis was performed from October 2021 to April 2022.

EXPOSURES

Opioid tapering, defined as 15% or more relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period after the stable baseline period.

MAIN OUTCOMES AND MEASURES

Emergency or hospital encounters for drug overdose or withdrawal and mental health crisis (depression, anxiety, or suicide attempt). Outcome counts were assessed in pretaper and postinduction periods (from 12 to 24 months after taper initiation).

RESULTS

The study included 21 515 tapering events among 19 377 patients with a mean (SD) of 9.1 (2.7) months of postinduction follow-up per event (median [IQR], 10 [8-11] months). Patients had a mean (SD) age of 56.9 (11.2) years, 11 581 (53.8%) were female, and 8217 (38.2%) had commercial insurance (vs Medicare Advantage). In conditional negative binomial regression analyses, adjusted incidence rate ratios for the postinduction period compared with the pretaper period were 1.57 (95% CI, 1.42-1.74) for overdose or withdrawal and 1.52 (95% CI, 1.35-1.71) for mental health crisis.

CONCLUSIONS AND RELEVANCE

These findings suggest that opioid tapering was associated with increased rates of overdose, withdrawal, and mental health crisis extending up to 2 years after taper initiation.

Patient Perspectives on Improving Patient-Provider Relationships and Provider Communication During Opioid Tapering

BACKGROUND

Efforts to reduce opioid overdose fatalities have resulted in tapering (i.e., reducing or discontinuing) opioid prescriptions despite a limited understanding of patients' experiences.

OBJECTIVE

To explore patients' perspectives on opioid taper experiences to ultimately improve taper processes and outcomes.

DESIGN

Qualitative study.

PARTICIPANTS

Patients on long-term opioid therapy for chronic pain who had undergone a reduction of opioid daily prescribed dosage of ≥50% in the past 2 years in two distinct medical systems and regions.

APPROACH

From 2019 to 2020, we conducted semi-structured interviews that were audio-recorded, transcribed, systematically coded, and analyzed to summarize the content and identify key themes regarding taper experiences overall and with particular attention to patient-provider relationships and provider communication during tapers.

KEY RESULTS

Participants (n=41) had lived with chronic pain for an average of 17.4 years (range, 3-36 years) and described generally adverse experiences with opioid tapers, the initiation of which was not always adequately justified or explained to them. Consequences of tapers ranged from minor to substantial and included withdrawal, mobility issues, emotional distress, exacerbated mental health symptoms, and feelings of social stigmatization for which adequate supports were typically unavailable. Narratives highlighted the consequential role of patient-provider relationships throughout taper experiences, with most participants describing significant interpersonal challenges including poor provider communication and limited patient engagement in decision making. A few participants identified qualities of providers, relationships, and communication that fostered more positive taper experiences and outcomes.

CONCLUSIONS

From patients' perspectives, opioid tapers can produce significant physical, emotional, and social consequences, sometimes reducing trust and engagement in healthcare. Patient-provider relationships and communication influence patients' perceptions of the quality and outcomes of opioid tapers. To improve patients' experiences of opioid tapers, tapering plans should be based on individualized risk-benefit assessments and involve patient-centered approaches and improved provider communication.

Abrupt Discontinuation From Long-Term Opioid Therapy in Massachusetts, 2015-2018

INTRODUCTION

In response to the opioid overdose crisis, providers were urged to taper and discontinue patients from long-term opioid therapy; however, abrupt discontinuation may lead to poor health outcomes. This study aims to determine abrupt and tapered discontinuation rates and identify the patient and provider characteristics associated with abrupt discontinuation.

METHODS

Data were from the Massachusetts Prescription Monitoring Program, 2015-2018. Patients discontinued from long-term opioid therapy were included in the analysis. Differences between abrupt and tapered discontinuations were identified with bivariate correlations, and variables independently associated with abrupt discontinuation were identified using multivariable Poisson regression analyses. Data were analyzed during 2019-2021.

RESULTS

In total, 277,485 patients experienced 359,320 discontinuations, of which 33.7% (n=120,964) were abrupt. Of all discontinuations, 55.7% were among female patients, and 57.9% were among patients aged >55 years. The ratio of abrupt to tapered discontinuations increased from 1:2.11 in 2015 to 1:1.75 in 2018. In bivariate analysis, prescribers with more patients receiving monthly opioid prescriptions were less likely to abruptly discontinue patients (29.0, IQR=13.9, 55.3 vs 18.8, IQR=5.84, 43.9, p<0.001), as were prescribers who wrote more monthly opioid prescriptions (36.0, IQR=16.8, 70.8 vs 25.4, IQR=7.40, 58.3, p<0.001). Multivariable results indicated that abrupt discontinuation was independently associated with male sex (RR=1.31, 95% CI=1.29, 1.1.32), younger age (RR=0.872, 95% CI=0.869, 0.874), greater distance between patient and prescriber (RR=1.0075, 95% CI=1.0072, 1.0078), and longer long-term opioid therapy duration (RR=1.021, 95% CI=1.021, 1.0122 for every month increase).

CONCLUSIONS

Among all long-term opioid therapy discontinuations, abrupt discontinuation is increasing. Evidence-based approaches to managing and tapering long-term opioid therapy are urgently needed.

Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

BACKGROUND

After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing.

OBJECTIVE

To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013-2014.

DESIGN

Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies.

PATIENTS

273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017-2018.

INTERVENTIONS

Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases.

MAIN MEASURES

Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview.

KEY RESULTS

The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: -52.0 MME [95% confidence interval: -109.9, -10.6]; year 2: -106.2 MME [-195.0, -34.6]; year 3: -98.6 MME [-198.7, -23.9]; year 4: -72.6 MME [-160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [-0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year.

CONCLUSIONS

Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change.

Developing a Curriculum for Addressing the Opioid Crisis: A National Collaborative Process

BACKGROUND

The burgeoning use of opioids and the lack of attention to the safe prescribing, storage, and disposal of these drugs remains a societal concern. Education plays a critical role in providing a comprehensive response to this crisis by closing the training gaps and empowering the next generation of physicians with the knowledge, skills, and resources needed to diagnose, treat and manage pain and substance use. Curricular Development: The Association of Faculties of Medicine of Canada (AFMC) developed a competency-based, bilingual curriculum for undergraduate medical students to be implemented in all Canadian medical schools. The authors describe the principles and framework for developing a national curriculum. The curriculum design process was situated in the Knowledge to Action theoretical framework. Throughout the development of this curriculum, different stakeholder groups were engaged, and their needs and contexts were considered.

CONCLUSION

The curriculum ensures that consistent information is taught across all medical schools to educate future physicians on pain management, opioid stewardship and substance use disorder.

Preoperative Opioid Utilization Patterns and Postoperative Opioid Utilization: A Retrospective Cohort Study

BACKGROUND

Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors hypothesized that decreasing utilization would be associated with improved outcomes and increasing utilization with worsened outcomes.

METHODS

Using commercial insurance claims, the authors identified 57,019 chronic opioid users (10 or more prescriptions or 120 or more days supplied during the preoperative year), age 18 to 89 yr, undergoing one of 10 surgeries between 2004 and 2018. Patients with a 20% or greater decrease or increase in opioid utilization between preoperative days 7 to 90 and 91 to 365 were compared to patients with less than 20% change (stable utilization). The primary outcome was opioid utilization during postoperative days 91 to 365. Secondary outcomes included alternative measures of postoperative opioid utilization (filling a minimum number of prescriptions during this period), postoperative adverse events, and healthcare utilization.

RESULTS

The average age was 63 ± 13 yr, with 38,045 (66.7%) female patients. Preoperative opioid utilization was decreasing for 12,347 (21.7%) patients, increasing for 21,330 (37.4%) patients, and stable for 23,342 (40.9%) patients. Patients with decreasing utilization were slightly less likely to fill an opioid prescription during postoperative days 91 to 365 compared to stable patients (89.2% vs. 96.4%; odds ratio, 0.323; 95% CI, 0.296 to 0.352; P < 0.001), though the average daily doses were similar among patients who continued to utilize opioids during this timeframe (46.7 vs. 46.5 morphine milligram equivalents; difference, 0.2; 95% CI, -0.8 to 1.2; P = 0.684). Of patients with increasing utilization, 93.6% filled opioid prescriptions during this period (odds ratio, 0.57; 95% CI, 0.52 to 0.62; P < 0.001), with slightly lower average daily doses (44.3 morphine milligram equivalents; difference, -2.2; 95% CI, -3.1 to -1.3; P < 0.001). Except for alternative measures of persistent postoperative opioid utilization, there were no clinically significant differences for the secondary outcomes.

CONCLUSIONS

Changes in preoperative opioid utilization were not associated with clinically significant differences for several postoperative outcomes including postoperative opioid utilization.

EDITOR’S PERSPECTIVE

Long-term Patterns of Self-reported Opioid Use, VACS Index, and Mortality Among People with HIV Engaged in Care

Longitudinal analyses of opioid use and overall disease severity among people with HIV (PWH) are lacking. We used joint-trajectory and Cox proportional hazard modeling to examine the relationship between self-reported opioid use and the Veterans Aging Cohort Study (VACS) Index 2.0, a validated measure of disease severity and mortality, among PWH engaged in care. Using data from 2002 and 2018, trajectory modeling classified 20% of 3658 PWH in low (i.e., lower risk of mortality), 40% in moderate, 28% in high, and 12% in extremely high VACS Index trajectories. Compared to those with moderate VACS Index trajectory, PWH with an extremely high trajectory were more likely to have high, then de-escalating opioid use (adjusted odds ratio [AOR], 95% confidence interval [CI] 5·17 [3·19-8·37]) versus stable, infrequent use. PWH who report high frequency opioid use have increased disease severity and mortality risk over time, even when frequency of opioid use de-escalates.

Opioid Tapering/Detoxification Protocols, A Compendium: Narrative Review

OBJECTIVES

The opioid epidemic has put pressure on clinicians to taper their chronic pain patients (CPPs) from opioids. This has resulted in rapid or forced tapers and opioid discontinuation. Partially responsible is lack of information on how to taper (tapering protocols).The objectives of this narrative review were then the following: compile all the published opioid tapering/detoxification protocols from the pain/drug rehabilitation/psychiatric literature whether for inpatient or outpatient use; organize these into general types; compare the types for advantages/disadvantages for use by a clinician in an outpatient setting; and answer some commonly asked questions relating to opioid tapering.

METHODS

Relevant references were identified by a search strategy utilizing the terms tapering, tapering protocols, detoxification, detoxification protocols, withdrawal, dependence, addiction, and drug rehabilitation. These were explored with the term opioids. Identified abstract were reviewed for any study relating to the objectives of this review. Those studies were then included in this review. As this is a narrative review, no quality ratings of these references were performed.

RESULTS

Of 1,922 abstracts identified by this search strategy, 301 were reviewed in detail for potential inclusion. Of these, 104 were utilized in this review. Nine types of opioid tapering protocols were identified and compared in tabular form. Twenty-two questions in reference to opioid tapering were addressed.

CONCLUSIONS

Based on this review, the protocol utilizing the opioid of current use is the simplest to use as it requires no rotation to another opioid and thereby avoids rotation errors. It also has behavior advantages.

Inches, Centimeters, and Yards: Overlooked Definition Choices Inhibit Interpretation of Morphine Equivalence

OBJECTIVE

Morphine-standardized doses are used in clinical practice and research to account for molecular potency. Ninety milligrams of morphine equivalents (MME) per day are considered a "high dose" risk threshold in guidelines, laws, and by payers. Although ubiquitously cited, the "CDC definition" of daily MME lacks a clearly defined denominator. Our objective was to assess denominator-dependency on "high dose" classification across competing definitions.

METHODS

To identify definitional variants, we reviewed literature and electronic prescribing tools, yielding 4 unique definitions. Using Prescription Drug Monitoring Programs data (July to September 2018), we conducted a population-based cohort study of 3,916,461 patients receiving outpatient opioid analgesics in California (CA) and Florida (FL). The binary outcome was whether patients were deemed "high dose" (>90 MME/d) compared across 4 definitions. We calculated I2 for heterogeneity attributable to the definition.

RESULTS

Among 9,436,640 prescriptions, 42% overlapped, which led denominator definitions to impact daily MME values. Across definitions, average daily MME varied 3-fold (range: 17 to 52 [CA] and 23 to 65 mg [FL]). Across definitions, prevalence of "high dose" individuals ranged 5.9% to 14.2% (FL) and 3.5% to 10.3% (CA). Definitional variation alone would impact a hypothetical surveillance study trying to establish how much more "high dose" prescribing was present in FL than CA: from 39% to 84% more. Meta-analyses revealed strong heterogeneity (I2 range: 86% to 99%). In sensitivity analysis, including unit interval 90.0 to 90.9 increased "high dose" population fraction by 15%.

DISCUSSION

While 90 MME may have cautionary mnemonic benefits, without harmonization of calculation, its utility is limited. Comparison between studies using daily MME requires explicit attention to definitional variation.

Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement

OBJECTIVE

Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework.

DESIGN AND SETTING

Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system.

METHODS

Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework.

RESULTS

Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%.

CONCLUSIONS

In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.

"I felt like I had a scarlet letter": Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain

BACKGROUND

Efforts to address opioid-involved overdose fatalities have led to widespread implementation of various initiatives to taper (i.e., reduce or discontinue) opioid prescriptions despite a limited understanding of patients' experience.

METHODS

From 2019-2020, we recruited patients with chronic, non-cancer pain who had undergone a reduction in opioid daily dosage of ≥50 % in the past two years at Boston Medical Center or Michigan Medicine. Participants completed semi-structured interviews exploring health history, opioid use, and taper experiences. Inductive analysis, guided by theoretical conceptualizations of structural stigma, identified emergent themes.

RESULTS

Among 41 participants, three elements of structural stigma were identified across participants' lives. First, participants identified themselves as overlooked subjects of the U.S. opioid crisis, who experienced overprescribing, subsequent stigmatization and surveillance of opioid use (e.g., toxicology screening, "pill counts"), and various tapering initiatives. Second, during the course of pain treatment, participants felt stigmatized and invalidated by cultural norms linking chronic pain to stereotypes of acting disingenuously (e.g., "drug-seeking"). Finally, during and after tapers, institutional policies and programs further increased participants' feelings of marginalization, producing multiple unintended consequences, including reduced access to medical care and feeling "orphaned by the system."

CONCLUSIONS

Opioid tapers may exacerbate the social production and burden of stigma among patients with chronic pain, especially when processes are perceived to invalidate pain, endorse stereotypes, and label previously effective, acceptable treatment as inappropriate. Findings highlight how various tapering initiatives reinforce the devalued status of people living with chronic pain while also reducing patients' wellbeing and confidence in medical systems.

Assessing the effectiveness of a narrative-based patient education video for promoting opioid tapering

OBJECTIVE

To compare effectiveness of a narrative-based educational video versus an informational pamphlet for increasing patients' self-efficacy and intention to taper their opioid use.

METHODS

Five thousand participants recruited from MTurk were screened to identify eligible patients. Eligible participants (n = 365, 49.9 % female, mean age = 37 years) were randomized to either watch the narrative video or read the pamphlet. Linear regression models were used for the main analysis.

RESULTS

Participants' perceptions of tapering effectiveness were higher in the video group (mean = 4.06) than the pamphlet group (mean = 3.67), adjusted mean difference = 0.34, 95 %CI 0.13 - 0.54,P < 0.001. Participants' perceptions of tapering self-efficacy were also higher in the video group (mean = 3.97) than the pamphlet group (mean = 3.60), adjusted mean difference = 0.32, 95 %CI 0.09 - 0.55, P < 0.001. Perceived tapering effectiveness and self-efficacy were both positively associated with post-intervention tapering intention (Spearman rank correlation coefficient = 0.38 and 0.53, respectively, both P < 0.001).

CONCLUSION

A narrative-based video about opioid tapering enhanced patients' perceptions of the effectiveness of tapering and their tapering self-efficacy.

PRACTICE IMPLICATIONS

Narrative-based videos may be effective for changing patient attitudes about opioid tapering.

Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain: a Rapid Review

BACKGROUND

Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide.

METHODS

We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking.

RESULTS

We included 49 studies-1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown.

DISCUSSION

The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm.

Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction. An interdisciplinary panel of pain clinicians and one patient advocate formulated recommendations on tapering methods and ongoing pain management in primary care with emphasis on patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective.

Nonconsensual Dose Reduction Mandates are Not Justified Clinically or Ethically: An Analysis

This manuscript describes the institutional and clinical considerations that apply to the question of whether to mandate opioid dose reduction in patients who have received opioids long-term. It describes how a calamitous rise in addiction and overdose involving opioids has both led to a clinical recalibration by healthcare providers, and to strong incentives favoring forcible opioid reduction by policy making agencies. Neither the 2016 Guideline issued by the Centers for Disease Control and Prevention nor clinical evidence can justify or promote such policies as safe or effective.

Opioid Management: Initiating, Monitoring, and Tapering

Numerous guidelines targeting safe use of opioids for chronic pain have been published but substantial challenges persist in clinical application of best practice recommendations. This article describes a pragmatic approach to clinical care of adults with chronic pain receiving long-term opioid therapy. Three components of care are emphasized: (1) medical and mental health assessment before initiating opioid therapy, (2) clinical surveillance during the course of long-term opioid therapy, and (3) clinical considerations and strategies governing opioid tapering. A pressing need exists for ongoing research to further clarify the optimal role that long-term opioid therapy has in treatment of chronic pain.

Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis

Background

There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently, there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use.

Methods

The current study details a retrospective review of 240 patients with chronic pain and LTOT presenting for treatment at a specialty opioid refill clinic. Patients first were initiated on an outpatient taper or, if taper was not tolerated, transitioned to buprenorphine. This study analyzes potential predictors of successful tapering, successful buprenorphine transition, or failure to complete either intervention and the effects of this clinical approach on pain intensity scores.

Results

One hundred seven patients (44.6%) successfully tapered their opioid medications under the Centers for Disease Control and Prevention guideline target dose (90 mg morphine-equianalgesic dosage), 45 patients (18.8%) were successfully transitioned to buprenorphine, and 88 patients (36.6%) dropped out of treatment: 11 patients during taper, eight during buprenorphine transition, and 69 before initiating either treatment. Conclusions. Higher initial doses of opioids predicted a higher likelihood of requiring buprenorphine transition, and a co-occurring benzodiazepine or z-drug prescription predicted a greater likelihood of dropout from both interventions. Patterns of change in pain intensity according to treatment were mixed: among successfully tapered patients, 52.8% reported greater pain and 23.6% reported reduced pain, whereas 41.8% reported increased pain intensity and 48.8% reported decreased pain after buprenorphine transition. Further research is needed on predictors of treatment retention and dropout, as well as factors that may mitigate elevated pain scores after reduction of opioid dosing.