Tapering Long-term Opioid Therapy in Chronic Noncancer Pain

Abstract

Increasing concern about the risks and limited evidence supporting the therapeutic benefit of long-term opioid therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids. In addition to overt addiction or diversion, the presence of adverse effects, diminishing analgesia, reduced function and quality of life, or the absence of progress toward functional goals can justify an attempt at weaning patients from long-term opioid therapy. However, discontinuing opioid therapy is often hindered by patients' psychiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers. The aim of this article is to review the existing literature and formulate recommendations for practitioners aiming to discontinue long-term opioid therapy. Specifically, this review aims to answer the following questions: What is an optimal opioid tapering regimen? How can the risks involved in a taper be managed? What are the alternatives to an opioid taper? A PubMed literature search was conducted using the keywords chronic pain combined with opioid withdrawal, taper, wean and detoxification. Six hundred ninety-five documents were identified and screened; 117 were deemed directly relevant and are included. On the base of this literature review, this article proposes evidence-based recommendations and expert-based suggestions for clinical practice. Furthermore, areas of lack of evidence are identified, providing opportunities for further research.

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

“…Primary care clinicians should collaborate with mental health providers and with other specialists as needed to optimize nonopioid pain management (see Recommendation 1), as well as psychosocial support for anxiety related to the taper. More detailed guidance on tapering, including management of withdrawal symptoms has been published previously (30,201). If a patient exhibits signs of opioid use disorder, clinicians should offer or arrange for treatment of opioid use disorder (see Recommendation 12) and consider offering naloxone for overdose prevention (see Recommendation 8).…”

Optimizing Placebo and Minimizing Nocebo to Reduce Pain, Catastrophizing, and Opioid Use: A Review of the Science and an Evidence-Informed Clinical Toolkit

“…These common false beliefs are may be powerfully anchored with negative reinforcement in that re-administration of opioids eliminates noxious symptoms, including amplified pain. Unfortunately, current guidelines may be in some clinical cases too aggressive for chronic pain patients who often have been taking opioids for years or decades (Berna, Kulich, & Rathmell, 2015). Aggressive tapers may trigger withdrawal symptoms and unintended nocebo effects, thereby perpetuating the false beliefs that can maintain patients on opioids when they otherwise would have been interested in reducing or stopping opioids if offered a successful pathway forward.…”

Retrospective cohort study of healthcare utilization and opioid use following radiofrequency ablation for chronic axial spine pain in Ontario, Canada

“…Fifteen per cent of patients maintained their opioid dosing, which may relate to failure of the procedure or the use of opioids for unrelated pain conditions. In addition, tapering opioids can be challenging29; opioid use may not decrease despite RFA success. This possibility is supported by the finding that those who had a second RFA procedure (and were therefore suspected of having some degree of benefit from initial RFA) had similar mean opioid doses pre-post RFA as the entire opioid cohort.…”