Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain: a Rapid Review
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BACKGROUND: Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide. METHODS: We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking. RESULTS: We included 49 studies—1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown.
Prior Presentations This work is based on a full report that is available on the ESP website at https://www.hsrd.research.va.gov/publications/ esp/reports.cfm. The report was presented during an HSR&D Cyberseminar on August 27, 2019. Protocol Registration PROSPERO; CRD42019129110 Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-06253-8) contains supplementary material, which is available to authorized users. Received February 7, 2020 Accepted September 17, 2020
DISCUSSION: The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm. KEY WORDS: chronic pain; opioids; tapering. J Gen Intern Med DOI: 10.1007/s11606-020-06253-8 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2020
BACKGROUND
In response to the evolving crisis of opioid-related morbidity, mortality, and misuse fueled initially by prescription opioids,1 many clinicians have changed their approach
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