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Opioid dose reduction may benefit patients with chronic pain

Reducing or discontinuing long-term opioid therapy may improve pain, function and quality of life among patients with chronic pain; however, these findings are supported by very low-quality evidence, according to a review published in Annals of Internal Medicine.

“There is little evidence to guide clinicians in the process of opioid tapering, especially in primary care settings, where most opioid therapy is prescribed,” Joseph W. Frank, MD, MPH, from VA Eastern Colorado Health Care System and assistant professor of internal medicine at the University of Colorado School of Medicine, and colleagues wrote. “In addition, little is known about the risks and benefits of opioid tapering. ... The effects of opioid tapering on patient outcomes have not been systematically reviewed.”

Researchers performed a systematic review of electronic databases from inception through April 2017 to find studies that addressed dose reduction or discontinuation of long-term opioid therapy for chronic pain. They assessed study quality using the U.S. Preventive Services Task Force quality rating criteria and evidence quality using the Grading of Recommendations Assessment, Development and Evaluation system. Patient outcomes included pain severity, function, quality of life, opioid withdrawal symptoms, substance use and adverse events.

The researchers found 67 studies — 11 randomized trials and 56 observational studies — that examined eight intervention categories, such as interdisciplinary pain programs, buprenorphine-assisted dose reduction and behavioral interventions. The overall quality of evidence was low; study quality was good for only three studies, poor for 51 studies and fair for the remaining studies. Although many studies reported dose reduction, rates of opioid discontinuation varied across interventions. In the 40 studies that examined patient outcomes after opioid dose reduction, eight of the fair-quality studies reported improvement in pain severity, five of the fair-quality studies reported improvement in function and three of the fair-quality studies reported improvement in quality of life. In light of these findings, clinicians may consider explaining the potential benefits of opioid tapering with patients on long-term opioid therapy.

“Clinicians should consider referring patients to multidisciplinary pain programs, when available, or developing team-based approaches to support opioid tapering in outpatient practice. Given inadequate evidence on the risks of opioid tapering, caution and close monitoring are warranted during and after tapering; consideration of overdose prevention strategies, such as naloxone, may be prudent,” Frank and colleagues wrote. “Together, these strategies are well-aligned with the broader goal of patient-centered, evidence-based, effective chronic pain care.”

In a related editorial, Deborah Dowell, MD, MPH, and Tamara M. Haegerich, PhD, from the CDC, wrote that although these results provide positive evidence for reducing long-term opioid therapy, further research is needed, particularly in primary care settings where most opioids are prescribed. Although dose reduction presents many challenges in primary care, Dowell and Haegerich believe “slow and steady” changes can better benefit patients.

“It will be heartening for many clinicians and patients to realize that indefinite continuation of opioid therapy is not always a foregone conclusion,” they wrote. “It is possible to reduce opioid use and associated risks while reducing pain and improving function and quality of life.” – by Savannah Demko

Disclosure: The researchers report no relevant financial disclosures.