The drive to taper opioids: mind the evidence, and the ethics

Kertesz, Stefan G.; Manhapra, Ajay

doi:10.1038/s41394-018-0092-5

Cited by 11 publications

(10 citation statements)

References 26 publications

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“…This point-counterpoint of Spinal Cord Series and Cases highlights the contentious attitudes regarding opioid prescribing currently confronting clinicians treating people with severe pain and spinal cord damage (SCD). Opinions and options regarding the vexatious and challenging issue of opioid prescribing for these patients are offered by Kertesz and Manhapra [1], and Bryce [2].…”

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confidence: 99%

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Severe chronic pain following spinal cord damage: a pragmatic perspective for prescribing opioids

New

2018

Spinal Cord Ser Cases

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The controversial issue of prescribing opioids to people with spinal cord damage who have severe pain is discussed in this paper. The reasons for concern regarding the increase in opioid prescription over recent years are outlined, along with a summary of the major potential adverse outcomes associated with opioids, such as falls, respiratory suppression, adverse endocrine effects, cognitive impairment, and the potential for opioid abuse, addiction and death. Situations when opioids are more appropriate are considered to be in the immediate post-trauma or post-operative periods. More controversial is the use of opioids in chronic non-cancer pain. A brief review of the evidence regarding opioids in chronic non-cancer pain is presented, and strategies outlined for reducing the risk of adverse consequences from opioid use in chronic non-cancer pain. These strategies include considerations before starting opioids, during initiation, monitoring activities and the cessation process. A vital consideration before starting opioids includes ensuring that all alternatives to opioids have been fully considered and trialled. Finally, some pragmatic proposals for prescribing opioids in people with SCD are suggested. It is recommended that before opioids are commenced, that the informed consent process should be complimented by a treatment agreement, with an initial 4-week trial period, and close monitoring of established goals.

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confidence: 99%

“…The paper by Kertesz and Manhapra [1] focuses on issues regarding the weaning of opioids. They assert that opioids should be gradually weaned to 90 mg/day or less in patients experiencing harm in excess of definite benefit and in other patients who agree.…”

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confidence: 99%

Severe chronic pain following spinal cord damage: a pragmatic perspective for prescribing opioids

New

2018

Spinal Cord Ser Cases

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“…1,[9][10][11][12][13][14][15] Resultant harms may include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, worsening function, and suicidality. 9,11,[15][16][17][18][19] A complicating factor in long-term opioid therapy (LTOT) is that multiple agencies influence clinical decisions. Notably, in 2016, the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic PaindUnited States was issued to guide primary care clinicians who were considering initiating or continuing opioid prescriptions.…”

Section: N Recent Years Prescribers In the Unitedmentioning

confidence: 99%

“…1,22 These circumstances particularly affect so-called legacy patients, patients already receiving LTOT who seek continuation of opioid therapy with a new physician after losing access elsewhere. 18 Frequently, health care systems fail to facilitate transition of care when primary opioid prescribers leave their practice; therefore, these patients, some of whom have been receiving LTOT for years, often present as desperate for a source of continuing LTOT. Concurrently, clinicians feel pressure to reduce or discontinue LTOT from health care organizations, ethical guidelines, insurance and pharmacy policies, and even the US Drug Enforcement Administration (DEA).…”

Section: N Recent Years Prescribers In the Unitedmentioning

confidence: 99%

Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Covington

Argoff

Ballantyne

et al. 2020

Mayo Clinic Proceedings

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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 longterm 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.

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“…Shortly after its publication, Atkinson et al51 wrote an article on the “pendulum swinging too far”, noting the damage that was being done to patients. Subsequently, numerous articles on the topic have been written not only by pain specialists52–56 but by other health care professionals,57,58 including addiction medicine specialists59–61 and bioethicists 62,63. Mainstream media has finally begun to recognize the plight of patients with pain, with the number of articles written on the gravity of the situation progressively increasing 64–70.…”

Section: Efforts To Curb the “Prescription Opioid Crisis”mentioning

confidence: 99%