https://immattersacp.org/weekly/archives/2017/07/18/1.htm

Tapering long-term opioid therapy may improve outcomes in chronic pain, review finds

An editorial called the possibility of discontinuing opioids while reducing pain and improving function and quality of life heartening, and encouraged physicians to work to reduce or discontinue long-term opioids.


Helping patients with chronic pain taper or discontinue long-term opioid therapy may improve their pain, function, and quality of life, according to a recent systematic review.

Researchers reviewed 67 studies with about 12,500 patients (11 randomized trials and 56 observational studies) that assessed the effectiveness of eight intervention categories (e.g., interdisciplinary pain programs, buprenorphine-assisted dose reduction, behavioral interventions) to reduce or discontinue long-term opioid therapy (defined as greater than one year) in patients with chronic pain (defined as pain lasting more than three months).

Results were published online on July 18 by Annals of Internal Medicine.

Overall, the quality of evidence was very low: Study quality was poor for 51 studies, fair for 13 studies, and good for three studies. Interventions occurred in outpatient settings (42 studies), inpatient settings (15 studies), or both (10 studies), but only five studies were conducted in primary care settings.

Many studies reported positive outcomes of interventions to reduce opioid use. For example, in 10 fair-quality studies of programs that mandated opioid discontinuation as a condition of enrollment, 87% of participants discontinued opioid use after completing the program (range, 74% to 100%).

Forty of the studies (five randomized controlled trials and 35 observational studies) examined patient outcomes after dose reduction (e.g., pain severity, pain-related function, quality of life, withdrawal symptoms, substance use, adverse events). Although the overall quality of evidence was very low, studies found improvement in pain severity (eight of eight fair-quality studies), function (five of five fair-quality studies), and quality of life (three of three fair-quality studies) after opioid dose reduction.

The authors noted limitations to their review, such as how the studies had heterogeneous interventions and outcome measures. They added that most studies involved voluntary participants, so results may not be generalizable to patients whose therapy is involuntarily reduced or discontinued.

Although results of the review must be confirmed with more and higher-quality studies, they show evidence of benefit for patients with chronic pain who work with their clinicians to reduce or discontinue long-term opioid therapy, an accompanying editorial noted.

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

A separate study about discontinuing opioids, a randomized trial published online on July 12 by JAMA Psychiatry, compared a seven-day taper of tramadol extended-release versus clonidine versus buprenorphine to manage withdrawal symptoms in 103 participants with opioid use disorder in a residential research setting. Researchers concluded that tramadol extended-release is more effective than clonidine and comparable to buprenorphine in reducing withdrawal symptoms during a residential tapering program.