Factors associated with opioid-tapering success: A mixed methods study

Kuntz, Jennifer L; Dickerson, John F.; Schneider, Jennifer L.; Firemark, Alison; Papajorgji-Taylor, Dea; Slaughter, Matthew; Reese, Katherine R.; Thorsness, Lou Ann; Sullivan, Mark D.; DeBar, Lynn; Smith, David H.

doi:10.1016/j.japh.2020.12.019

Cited by 14 publications

(15 citation statements)

References 31 publications

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“…Primary care prescriber education and an opioid tapering referral programme was associated with a mean dose reduction of 111 mg oral morphine equivalent (P value not reported) over 12 months. 146 Prescriber education and a dose reduction policy was associated with a mean dose reduction of 64 mg oral morphine equivalent (95% confidence interval 32 to 96, P<0.001) over 16 months. 203 For patients with a new diagnosis of depression, adherence to antidepressants increased the odds of opioid cessation (hazard ratio 1.24, P=0.007).…”

Section: Resultsmentioning

confidence: 92%

“…The remaining 36 studies contributing to the evidence synthesis included 27 randomised controlled trials, 46 47 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 212 213 five non-randomised controlled trials, 79 82 83 84 86 and four uncontrolled studies. 126 146 182 203 Meta-analysis was conducted on 11 randomised controlled trials 46 47 53 54 56 57 59 65 68 72 73 ( fig 1 and appendices 3-5).…”

Section: Resultsmentioning

confidence: 99%

“…In 12 studies, some or all patients had chronic pain and comorbid prescription opioid use disorder, opioid dependence, or previous substance use. 49 55 60 61 64 67 70 71 79 146 182 203 …”

Section: Resultsmentioning

confidence: 99%

“…Studies that accounted for underlying trends in opioid use before the intervention and observed changes during and after the intervention were deemed at serious risk of bias. 126 146 203 Their results were synthesised, but because these studies did not perform time series comparisons of projected versus actual observations, they could not be considered equivalent to randomised controlled trials. One study with serious risk of bias that did not assign patients to intervention and control groups was considered to approximate a non-randomised controlled trial.…”

Section: Discussionmentioning

confidence: 99%

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Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

Avery

McNeilage

Stanaway

et al. 2022

BMJ

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ObjectiveTo review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.DesignSystematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.Data sourcesMedline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.Eligibility criteria for study selectionOriginal research in English. Case reports and cross sectional studies were excluded.Data extraction and synthesisTwo authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).ResultsOf 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers’ adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference –6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, −14.31 mg daily oral morphine equivalent, 95% confidence interval −21.57 to −7.05).ConclusionsEvidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.Review registrationPROSPERO CRD42020140943.

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Section: Resultsmentioning

confidence: 92%

Section: Resultsmentioning

confidence: 99%

“…In 12 studies, some or all patients had chronic pain and comorbid prescription opioid use disorder, opioid dependence, or previous substance use. 49 55 60 61 64 67 70 71 79 146 182 203 …”

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

Avery

McNeilage

Stanaway

et al. 2022

BMJ

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“…However, we can see that even if the mass uniformity test is satisfied, the dose contained in the capsules can vary by up to 25% 11. This can be of interest for healthcare professionals who prepare unit doses for tapering medications 12. Compounding pharmacists may also be required to design and prepare oral suspensions of medications.…”

Section: Discussionmentioning

confidence: 99%

Process performance of a new liquid medication dispensing robot

Lagrange

2021

Eur J Hosp Pharm

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ObjectivesLiquid medications provide an alternative to splitting pills and dosages by measuring an amount of liquid rather than crushing tablets or opening capsules. Special attention should also be paid to specific patient groups with swallowing difficulties or requiring enteral feeding administration. Liquid medicines are also often used to ease withdrawal symptoms for people suffering from addiction. Nevertheless, filling liquid medication cups with the right medication and precise doses may be difficult for healthcare professionals. The Nooddis (‘Nominative Oral Dose Dispenser’—Pierre Lôo Hospital, France and Packinov, France) is a new robotic system for the automated filling of single dose liquid medications. Since the performance of such a complex piece of equipment depends on compliance of the service provider to our building guidelines, the process performance verification is a necessary prerequisite before starting routine production.MethodsThe performance of the Nooddis robot (accuracy, precision, and tapering calculation) and its ability to fill medicine cups was evaluated with 18 different liquid medications using an automatic in-line checkweigher. Microbiological testing was also performed.Results648 sealed cups were prepared for qualification. The filling accuracy was within the limit of ±10% from 75 µL to 21.25 mL. The repeatability (% relative SD (%RSD) 0.05 to 4.93) and intermediate precision (%RSD 0.01 to 6.59) were validated for all preparations. All medicine cups met the requirements of USP and European Pharmacopoeia acceptance criteria for microbiological quality. Automated tapering calculations allowed for easy production of daily doses for the tapering periods chosen.ConclusionSince the system met the required quality standards, the Nooddis robot, with automatic in-line tapering system, is regarded as an accurate technology that can fill the exact amount of liquid oral medication in single dose cups. This may promote closer monitoring, which supports medication tapering as well as medication misuse prevention. With a packaging cost similar to current unit dose cup systems, it is a relevant alternative to fractioned or crushed tablets, as well as opened capsules. Further developments for some sterile liquid medications are yet to be studied.

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Opioid tapering and mental health crisis in older adults

Maharjan,

Ramachandran,

Bhattacharya

et al. 2023

Pharmacoepidemiology and Drug

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BackgroundOpioid tapering and discontinuation have increased in recent years with the implementation of national prescribing guidelines. This study aimed to examine the relationship between opioid tapering velocity and mental health crisis events in older Medicare beneficiaries.MethodsA nested case–control study was conducted using the 2012–2018, 5% national Medicare claims data. Older adults with chronic non‐cancer pain (CNCP) who were receiving long‐term opioid therapy (LTOT) were included in the study. Cases were defined as individuals experiencing mental health crisis events; controls were identified using incidence density sampling. The opioid tapering velocity was measured in the 120‐day hazard period that yielded a monthly percentage of dose change. Conditional logistic regression was used to assess the relationship of interest.ResultsA total of 42 091 older adults with CNCP were eligible for the study. Cases (n = 952) were matched with controls in a 1:2 ratio based on age (±1 year) and time of cohort entry (±30 days). A higher percentage of controls (67.65%) were on steady dose compared with cases (59.03%). In the adjusted model, tapering (aOR = 1.36; 95% CI: 1.02–1.83), rapid tapering (aOR = 1.45; 95% CI: 1.11–1.91), and dose escalation (aOR = 1.78; 95% CI: 1.32–2.39) were significantly associated with the mental health crisis, compared with steady dose.ConclusionBoth opioid tapering and dose escalation are associated with mental health crisis events. Patient‐driven and gradual dose tapering, as recommended by prescribing guidelines, should be promoted to prevent mental health crisis events among older adults on LTOT.

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Factors associated with opioid-tapering success: A mixed methods study

Cited by 14 publications

References 31 publications

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

Process performance of a new liquid medication dispensing robot

Opioid tapering and mental health crisis in older adults

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