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

Abstract

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.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia

“…Reviews of interventions designed to support opioid tapering for CNCP generally report that inadequate evidence is available to guide primary care practitioners (PCPs) in their management of opioid reduction for patients experiencing CNCP 4,5,9,12,30,31 . Most of the studies that we identified were conducted in the US, in academic settings, Veteran Affairs clinics, or safety net clinics located in hospitals.…”

“…There is evidence to suggest that tapering can be achieved without increased levels of pain and loss of functional capacity, especially when tapering occurs slowly 16,19,30 . The biggest gap in evidence lies in evaluating which patients or tapering characteristics are associated with benefit or harm 5 . This gap needs to be addressed to assuage the front‐of‐mind fear for both PCPs and patients, particularly in relation to accidental overdose and adverse events relating to mental health.…”

“…Higher opioid doses have been associated with significant risk, including overdose, opioid use disorder, depression, suicide, motor vehicle accidents and fractures 4 . These risks may be reduced by tapering opioid doses, but there is insufficient evidence to guide safe and effective tapering, especially in rural contexts 5 …”

Veteran engagement in opioid tapering research: a mission to optimize pain management

“… 19 , 39 Similarly, the Centers for Disease Control and Prevention recommends additional caution for prescribing >50 mg morphine equivalent daily dose (MEDD) and recommends against >90 mg MEDD. 16 In general, the recommendation is to keep opioid therapy at the lowest dosage and shortest duration possible, in conjunction with the implementation of opioid risk mitigation strategies 26 and consideration of issues related to telehealth, care coordination, stepped care model implementation, 19 and suicide prevention. 34 …”

“…This may include those on low MEDDs who are not appropriate for rescue (ie, “breakthrough”) medications and patients with comorbid complex opioid dependence who may be more appropriate for other OUD treatments (eg, buprenorphine). 26 …”