The Conundrum of Opioid Tapering in Long-Term Opioid Therapy for Chronic Pain: A Commentary

• 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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“…However, data to justify forced dose tapering in the otherwise stable patient is weak, and the 2016 Guideline of the Centers for Disease Control and Prevention (CDC) chose not to endorse this course of action [12]. Forced tapers, slow or fast, can harm previously stable patients [13], while crossing ethical lines doctors normally respect. Advocates for this approach have stepped ahead of data, when available science dictates a more tempered approach.…”

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confidence: 99%

“…But, unavoidably, this same combination of effects, precisely what makes opioids effective, also makes opioids subject to dependence. One of us has termed this "the boon and the curse" of opioids [13]. Estimates for the emergence of aberrant behaviors vary among sample and study designs, with rates reported of between 3 [21] and 17% [22].…”

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confidence: 99%

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The drive to taper opioids: mind the evidence, and the ethics

Kertesz

Manhapra²

2018

Spinal Cord Ser Cases

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The high prevalence of pain in patients with spinal cord injury, coupled with a national recalibration of opioid prescribing, presents a challenge. Prescribers may attempt to taper opioids, where observable harms from the prescribed opioid appear to outweigh benefits, a stance endorsed by the 2016 Guideline for Prescribing Opioids for Chronic Pain, issued by the Centers for Disease Control and Prevention. Different considerations apply when clinicians wish to reduce doses in adherent and stable patients, absent their consent. In this perspective piece, we acknowledge the problematic nature of opioids as a treatment. However, forced tapers may destabilize patients and clinical evidence to support forced tapers is lacking. We favor an ethic of informed consent when proposing changes to care involve meaningful risk, and suggest alternative approaches to optimizing safety.

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“…The deprescribing process may prove challenginggradual weaning may be derailed by an abstinence syndrome involving insomnia, emotional blunting, deficits in executive control and the exacerbation or re-emergence of comorbid psychiatric disorders. 28 If an attempt at deprescribing has been unsuccessful, it may be wise to plan a slower taper or consider opioid substitution therapy.…”

mentioning

confidence: 99%

Prescribing wellness: comprehensive pain management outside specialist services

Holliday¹,

Hayes²,

Jones³

et al. 2018

Aust Prescr

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The Conundrum of Opioid Tapering in Long-Term Opioid Therapy for Chronic Pain: A Commentary

Abstract: Awareness of the science of the neuroplasticity effects of repeated use of opioids is necessary to better manage these patients with complex challenges.

Cited by 81 publications

References 53 publications

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

The drive to taper opioids: mind the evidence, and the ethics

Prescribing wellness: comprehensive pain management outside specialist services

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