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Opioid tapering may improve pain, function, QoL in patients receiving LTOT

Stephen Padilla
11 Aug 2017
More than 33,000 have died in America from opioid overdose in 2015 alone.

A recent systematic review suggests that multiple strategies may be effective to reduce or discontinue long-term opioid therapy (LTOT) for chronic pain and that opioid reduction may improve pain, function and quality of life (QoL), but the quality of evidence is very low.

“In addition to discussing the goals and risks of opioid therapy, clinicians should consider discussing the potential benefits of opioid tapering with patients receiving LTOT,” according to researchers.

“Informed by the multidisciplinary care models among good- and fair-quality studies, clinicians should consider referring patients to multidisciplinary pain programmes, when available, or developing team-based approaches to support opioid tapering in outpatient practice,” they added.

A total of 67 studies (11 randomized trials and 56 observational studies) examining eight intervention categories, including interdisciplinary pain programmes, buprenorphine-assisted dose reduction and behavioural interventions, were identified. [Ann Intern Med 2017;167:181-191]

Quality of study was good in three studies and fair in 13. On the other hand, 51 studies had poor quality. Dose reduction was reported in many studies, but rates of opioid discontinuation ranged widely across interventions. In addition, there was very low overall quality of evidence.

Of the 40 studies that assessed patient outcomes after dose reduction (very low overall quality of evidence), eight were fair-quality observational studies. These fair-quality studies reported improvement in pain severity, function and QoL after opioid dose reduction.

“Though many studies reported positive dose reduction outcomes, the overall quality of evidence for effectiveness of all strategies to reduce or discontinue LTOT was very low due to methodological limitations across studies and an absence of adequately powered randomized trials,” researchers said.

“Although confidence is limited by the very low quality of evidence overall, findings from this systematic review suggest that pain, function and QoL may improve during and after opioid dose reduction,” they added.

Several potential mechanisms that may explain this finding are as follows: (1) Most interventions delivered concurrent nonopioid pain management approaches that may have provided more benefit than LTOT; (2) opioid dose reduction may lessen adverse effects of LTOT that can negatively affect function and QoL; (3) improvement after opioid dose reduction may be due to resolution of opioid-induced hyperalgesia, a response in which patients receiving opioids become more sensitive to painful stimuli. [Pain Physician 2011;14:145‒61]

“Finally, given the observational nature of most studies, we cannot exclude reverse causation (that is, patients successfully tapered opioids because pain severity decreased),” researchers said.

The authors recommended close monitoring and caution during and after opioid tapering, given inadequate evidence on its risks. Moreover, it is essential to consider overdose prevention strategies, such as naloxone. [Ann Intern Med 2016;165:245‒52]

In this study, researchers accessed Medline, Embase, PsycINFO, Cinahl and the Cochrane Library from inception through April 2017, as well as reference lists and expert contacts, for original research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain.

The authors evaluated evidence quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Prespecified patient outcomes were pain severity, function, QoL, opioid withdrawal symptoms, substance use and adverse events.

Some limitations of this study include heterogeneous interventions and outcome measures, as well as poor-quality studies with uncontrolled designs.

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