International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering

• The current United States opioid overdose crisis is a complex, multifaceted, public health emergency that urgently requires the implementation of evidence-based primary, secondary, and tertiary preventive interventions. We develop a typology of the stigma related to opioid use, showing how multiple dimensions of stigma continue to fundamentally hinder the response to the crisis. • Public stigma is driven by stereotypes about people with opioid use disorders, such as their perceived dangerousness or perceived moral failings, which translate into negative attitudes toward people with opioid use disorders. • Enacted stigma describes the behavioral manifestations of public stigma, including discrimination and social distancing. Public and enacted stigma, in turn, lead to delivery of suboptimal care and undermine access to treatment and harm reduction services. • Public stigma and enacted stigma can become structural stigma when they become encoded in cultural norms, laws, and institutional policies. Collectively, these forms of stigma run at cross purposes to-and reduce public support for-public health-oriented policies to address the opioid overdose crisis.

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“…[ [73][74][75][76][77][78]. Enacted stigma has also been directly associated with nonfatal overdose [79].…”

Section: The Us Opioid Overdose Crisis Response: Multiple Levels Of Pmentioning

confidence: 99%

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

et al. 2019

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“…Moreover, low quality evidence suggests that opioid tapering is often successful and may improve patients' pain, function, and quality of life [16,17]; however, all evidence relates to voluntary tapering. Mandatory opioid tapering is not recommended by the 2017 Canadian opioid guideline [4] and should not be pursued [18], in part because loss of prescription opioids, and resulting withdrawal symptoms may cause some patients to seek out illicit, more dangerous sources [19].…”

mentioning

confidence: 99%

Perceptions and Impact of the 2017 Canadian Guideline for Opioid Therapy and Chronic Noncancer Pain: A Cross-Sectional Study of Canadian Physicians

Busse

Douglas

Chauhan

et al. 2020

Pain Research and Management

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Background. Physician adherence to guideline recommendations for the use of opioids to manage chronic pain is often limited. Objective. In February 2018, we administered a 28-item online survey to explore perceptions of the 2017 Canadian guideline for opioid therapy and chronic noncancer pain and if physicians had altered practices in response to recommendations. Results. We invited 34,322 Canadian physicians to complete our survey, and 1,128 responded for a response rate of 3%; 687 respondents indicated they prescribed opioids for noncancer pain and answered survey questions about the guideline and their practice. Almost all were aware of the guideline, 94% had read the document, and 89% endorsed the clarity as good or excellent. e majority (86%) felt the guideline was feasible to implement, but 66% highlighted resistance by patients, and 63% the lack of access to effective nonopioid treatment as barriers. irty-six percent of respondents mistakenly believed the guideline recommended mandatory tapering for patients using high-dose opioid therapy (≥90 mg morphine equivalent per day), and 58% felt they would benefit from support for opioid tapering. Seventy percent of respondents had changed practices to align with guideline recommendations, with 51% engaging some high-dose patients in opioid tapering and 43% reducing the number of new opioid starts. Conclusion. ere was high awareness of the 2017 Canadian opioid guideline among respondents, and preliminary evidence that recommendations have changed practice to better align with the evidence. Ongoing education is required to avoid the misunderstanding that opioid tapering is mandatory, and research to identify effective strategies to manage chronic noncancer pain is urgently needed.

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“…The importance of this ongoing partnership is highlighted in a recent commentary that describes the crisis that has evolved in the United States related to forced opioid tapering among patients suffering from chronic pain, including recurrence of their pain conditions, worsening mental illness and suicide, profound loss of function, and chemical coping through use of other drugs of abuse. 35 In this context, in April 2019, the authors of the 2016 Center for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain 36 issued a clarification stating that the original guideline was not meant to encourage forced opioid tapering for patients taking longterm prescription opioids, nor did it support tapering to a predefined dose threshold. 37 Furthermore, the United States Food and Drug Administration has updated the prescribing information for opioid analgesics to include guidelines for a safe opioid taper for tolerant patients.…”

Section: Opioid Tapering Strategiesmentioning

confidence: 99%

Managing Cancer Pain, Monitoring for Cancer Recurrence, and Mitigating Risk of Opioid Use Disorders: A Team-Based, Interdisciplinary Approach to Cancer Survivorship

Goodlev

DiScala

Darnall

et al. 2019

Journal of Palliative Medicine

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Background: Palliative care (PC) teams increasingly care for patients with cancer into survivorship. Cancer survivorship transcends distinctions between acute, chronic, malignant, and nonmalignant pain. Partnering with oncologists, PC teams manage pain that persists after disease-directed treatment, evaluate changing symptoms as possible signs of cancer recurrence, taper opioids and mitigate risk of opioid misuse, and manage comorbid opioid use disorder (OUD). While interdisciplinary guidelines exist for pain management in survivorship, there is a need to develop a conceptual model that fully translates the biopsychosocial framework of PC into survivorship pain management. Objective: This review frames a model for pain management in cancer survivorship that balances analgesia with the imperative to minimize risk of OUD, recognizes signs of disease recurrence, and provides whole-person care. Methods: Comprehensive narrative review of the literature. Results: Little guidance exists for co-management of pain, psychological distress, and opioid misuse in survivorship. We identified themes for whole-person pain management in survivorship: use of opioids and coanalgesic medications to prevent recurrent pain from residual tissue damage following cancer treatment, opioid tapering to the lowest effective dose, utilization of nonpharmacologic psychological interventions shown to reduce pain, screening for and management of OUD in partnership with addiction medicine specialists, maintaining vigilance for disease recurrence, and engaging in shared medical decision making. Conclusions: The management of pain in cancer survivorship is complex and requires interdisciplinary care that balances analgesia with the imperative to reduce long-term inappropriate opioid use and manage OUD, while maintaining therapeutic presence with patients in the spirit of PC.

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International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering

Cited by 100 publications

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Stigma as a fundamental hindrance to the United States opioid overdose crisis response

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

Perceptions and Impact of the 2017 Canadian Guideline for Opioid Therapy and Chronic Noncancer Pain: A Cross-Sectional Study of Canadian Physicians

Managing Cancer Pain, Monitoring for Cancer Recurrence, and Mitigating Risk of Opioid Use Disorders: A Team-Based, Interdisciplinary Approach to Cancer Survivorship

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