Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Approximately 10 million U.S. adults are prescribed long-term opioid therapy (LTOT) for chronic pain despite inadequate evidence of long-term benefit and growing evidence of harms. Investigators conducting this systematic review examined the evidence on the effectiveness of strategies to reduce or discontinue LTOT prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Conducting literature searches in multiple databases from inception through April 19, 2017, investigators identified 67 studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions.
- This systematic review identified multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low.
- Common themes across intervention types can provide insight into the program components that may provide effective support of opioid tapering. In the 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies.
- Investigators identified 40 studies that assessed the effect of dose reduction or discontinuation of LTOT on patient outcomes, however, the overall quality of the evidence was very low.
- The fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies, and quality of life (3/3 studies) following opioid dose reduction.
- Few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
- To support Veterans during dose reduction or discontinuation of LTOT, facilities should seek to expand access to existing multidisciplinary pain programs, when available, or team-based approaches that incorporate treatment coordination and self-management (e.g., patient-centered medical homes, primary care-mental health integration).
- Given inadequate evidence on the risks of opioid tapering, study investigators suggest caution and close monitoring is warranted during and after opioid tapering; in addition, consideration of overdose prevention strategies (i.e., naloxone) may be prudent.
- There was substantial heterogeneity in measures of opioid dose reduction and of patient outcomes, as well as within clinically relevant domains of intervention components.
This study was funded by VA HSR&D's Quality Enhancement Research Initiative (QUERI). Dr. Frank is with HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care; Dr. Lovejoy is part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC); and Dr. Becker is with HSR&D's Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center.
Frank J, Lovejoy T, Becker W, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Annals of Internal Medicine. July 18, 2017;e-pub ahead of print.