Are Opioid Tapering Guidelines Impacting Use?

Rates of opioid prescribing for chronic noncancer pain have increased significantly in the last decade, along with rates of opioid abuse and dependence.
Rates of opioid prescribing for chronic noncancer pain have increased significantly in the last decade, along with rates of opioid abuse and dependence.
The following article features coverage from PAINWeek 2017 in Las Vegas, Nevada. Click here to read more of MPR's conference coverage.

LAS VEGAS – At Pain Week 2017, held September 5-9 in Las Vegas, Nevada, a presentation by Jennifer Hah, MD, MS, an instructor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University in California, focused on the risks of long-term opioid use for chronic noncancer pain, during which she reviewed guidelines regarding the tapering of these medications.1

Rates of opioid prescribing for chronic noncancer pain have increased significantly in the last decade, along with rates of opioid abuse and dependence.2 Prescription opioids represent the top cause of death resulting from overdose in the United States.3 Long-term use of these drugs has been linked to increased tolerance and physical dependence, immunosuppression, opioid-induced endocrinopathy, respiratory depression (the primary mechanism underlying opioid-related deaths), and elevated rates of depression and substance use disorders.

A large retrospective cohort study published in 2017 found that 5% of opioid-naive individuals who filled a prescription ultimately became long-term users, a risk shown to increase with the number of refills, higher dosages, and initiation of long-acting opioid.4 Other findings suggest addiction rates of up to 10% in patients who receive prescription opioids.5

According to guidelines from the American Pain Society and the American Academy of Pain Medicine, patients "who engage in repeated aberrant drug-related behaviors or drug abuse/diversion, experience no progress toward meeting therapeutic goals, or experience intolerable adverse effects" should be tapered or weaned off chronic opioid therapy.6 This can occur in inpatient or outpatient settings, depending on the patient's medical and psychiatric comorbidities. Tapering in both settings has been found to increase functioning and reduce pain, depression, and catastrophizing, according to findings reviewed in the presentation.

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Also covered were several brief, self-report tools to screen for aberrant drug-related behavior, including the Screener and Opioid Assessment for Patients with Pain-Revised, the Opioid Risk Tool, and the Current Opioid Misuse Measure, as well as various guidelines pertaining to the discontinuation of opioid therapy.7,8 Each set of guidelines recommends discontinuation in patients who are not responsive to treatment or experience serious adverse events.

"As guidelines are evolving and emerging regarding indications for tapering opioid therapy in the context of chronic non-cancer pain, there has been a growing awareness amongst providers," Dr Hah told MPR. "One indication that these recommendations may be leading to positive changes is the increased number of referrals we are seeing as pain specialists from primary care providers for assistance with opioid tapering." She noted several potential barriers to tapering, including limited access to specialists, lack of insurance, and patients' fear of discontinuing opioid use.

Read more of MPR's coverage of PAINWeek 2017 by visiting the conference page.

References

  1. Hah J, Prasad R. Crisis = opportunity: reducing medication burden while managing chronic pain. Presented at Pain Week 2017; September 5-9, 2017; Las Vegas, NV.
  2. Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug Alcohol Rev. 2011;30(3):264-270.
  3. Vital signs: overdoses of prescription opioid pain relievers---United States, 1999--2008. MMWR Morb Mortal Wkly Rep. 2011;60(3):1487-1492.
  4. Deyo RA, Hallvik SE, Hildebran C, et al. Association between initial opioid prescribing patterns and subsequent long-term use among opioid-naive patients: a statewide retrospective cohort study. J Gen Intern Med. 2017;32(1):21-27.
  5. Ballantyne JC, LaForge KS.  Pain. 2007; 129(3):235–255.
  6. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
  7. Kahan M, Mailis-Gagnon A, Wilson L, Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 1: general population. Can Fam Physician. 2011;57(11):1257-1266.
  8. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance. Pain Physician. 2012;15(3 Suppl):S67-S116.