Clinical Update Dec. 2018
Over the last 20 years, the liberal prescribing of opioids for chronic pain has created a population of patients who been on long term opioid therapy (LTOT) for several years if not decades. Many patients are on doses well above the CDC recommended upper limit of 90 Morphine Equivalent Dose (MED) for new starts. Patients, however, may be reluctant to taper, fearing withdrawal and increased pain. Prescribers are also asking whether or not tapering is necessary if the patient is stable and compliant on their current dose. Yet, overdose rates continue to be high compared to historical standard and it is well established that patients on high doses of opioids are at increased risk for a variety of side effects, serious morbidities, and death. Quality of life may be adversely affected, despite the fact that the patient perceives benefit in terms of pain relief. Recent research found no significant difference for pain relief between opioid and non-opioid treatment. (ref. The SPACE Randomized Clinical Trial)
For this legacy patient population, prescribers need to carefully assess the risks versus the benefits of continued opioid therapy. In some cases, where the risks are minimal and the patient appears to be doing well, continued opioid therapy may be justified. In many cases though a thorough and systematic risk benefit assessment (RBA) will reveal continued pain and dysfunction that indicate that a taper should be initiated and other non-opioid therapies some be employed, including referral to behavioral health or other specialists. A Systematic Review of 67 studies suggests that several types of interventions may be effective to reduce or discontinue LTOT and that pain, function, and quality of life may improve with opioid dose reduction, but the evidence is of very low quality (ref. A Systematic Review, by Frank et al 2017). It’s important to recognize that tapering is an art, not an exact science and the speed and duration of the taper should be tailored to the individual needs of the patient.
Below are some guidelines and tools that will help prescribers assess and weigh risks versus benefits, and decide whether tapering is indicated. For tapering to be successful, clinicians must approach the taper as an alliance with the patient with the goal of improving their safety and quality of life.
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