Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Abstract

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.

Opioid Taper is Associated with Improved Experimental Pain Tolerance in Patients with Chronic Pain: An Observational Study

“…However, a lack of improvement in pain-related function and quality of life, as well as mixed and nonsignificant effects on opioid-related pain modulation activities, should temper clinician motivation to taper a given patient’s opioid therapy to result in improved pain outcomes. As cautioned by Mackey and colleagues [ 35 ] and others [ 37 , 38 ], evidence for the benefits versus harms associated with opioid taper remains mixed, and, as promulgated by a recent American Academy of Pain Medicine Foundation consensus panel, these should not be attempted in patients with chronic pain without adopting “a patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective” (p. 2155 [ 39 ]).…”

Attitudes Toward a Pre-authorized Concealed Opioid Taper: A Qualitative Analysis of Patient and Clinician Perspectives

“…The Patient-Centered Outcome Research Institute (PCORI) published a 10-step patient engagement framework which would be instrumental in guiding the next steps in this line of research ( 48 – 50 ). Specifically, the 10-step framework is a model that can be used to integrate census opioid tapering recommendations with novel concealed opioid tapering approaches ( 51 ). Core patient engagement principles include shared decision making (e.g., involving patients in decisions regarding study design/implementation), co-learning (e.g., stakeholder participation on data safely monitoring boards), and partnership (e.g., patient engagement in dissemination of research results).…”

Effect of a Predictive Analytics-Targeted Program in Patients on Opioids: a Stepped-Wedge Cluster Randomized Controlled Trial

“…1 – 3 These efforts have typically focused on all patients with certain characteristics associated with risk, 4 – 8 including mental health diagnoses, substance use disorder, medical complexity, 9 – 13 care coordination challenges, 14 treatment disengagement, 15 and interacting pharmacotherapies. 16 , 17 While opioid safety initiatives can improve outcomes 18 , 19 , their effectiveness is limited by clinician time 20 , 21 and they potentially invite undertreatment of pain 22 , 23 and/or disengagement from care. The proactive identification of patients at high risk of adverse outcomes from opioid prescriptions and the provision of targeted, interdisciplinary case review could address these challenges and promote improvement in patient outcomes.…”