LAS VEGAS—Opioids have diverse and important functions, with opioid use and taper affecting many domains of experience and behavior. In fact, long-term opioid use patterns suggest that opioids treat not only physical pain, but social pain.
“While discontinuation of opioid use is rarely possible for those addicted, it looks possible with support for those not addicted,” according to a presentation at PAINWeek 2014 by Beth Darnall, PhD, Clinical Associate Professor, Stanford University, and Department of Anesthesiology, Perioperative & Pain Medicine, Division of Pain Medicine, Systems Neuroscience & Pain Laboratory, Palo Alto, CA; Sean Mackey, MD PhD, CPE, and Mark D. Sullivan, MD, PhD, of the University of Washington, Seattle, Washington. The speakers outlined psychological predictors for opioid prescription and dose as well as outcomes associated with structured opioid taper support trials.
They noted that chronic pain, which affects 100 million Americans, is increasing in incidence. This is mirrored in opioid prescribing trends, which have increased sharply between 1995 and 2010, with hydrocodone/acetaminophen the most prescribed drug in 2011, at 137 million prescriptions.
“The grand goals,” Dr. Darnall said, are to “help your patients avoid opioid prescription and, if patients are prescribed opioids, help them to minimize need and use.” She described four salient points describing the interface between opioids and psychology: sensory pain and negative emotions share neural circuitry; pain is defined as “an unpleasant sensory and emotional experience”; negative cognitive and emotional responses to pain (and to opioid taper) amplify pain, and stress amplifies pain.
Patients can be helped to reduce reliance on opioids by being educated about these points, and by being connected to community and online resource. In addition, “patients must develop confidence in their own ability to calm their nervous system,” because “pain psychology is more than learning to cope with pain.”
For example, patients can learn skills to modulate arousal, cognition and emotion, thereby calming their nervous system and directly influencing pain intensity and distress. This can be achieved with behavioral techniques such as diaphragmatic breathing, progressive muscle relaxation, meditation, and mindfulness based stress reduction, with less pain resulting in “fewer pills.”
Dr. Sullivan said most opioid therapy is short-term, “but once 90 days of continuous therapy is received, use often persists for years,” with persistence predicted by high daily opioid dose and misuse. In fact, most “ideal” candidates discontinue therapy before reaching 90 days, either due to side effects or lack of efficacy.
Many patients on long-term opioid therapy are ambivalent, stating, they “would love to stop” if they could. However, fear of pain and withdrawal symptoms is more important to patients than actual pain and withdrawal symptoms, Dr. Sullivan noted. Patients should institute a taper of 10% of the original dose per week until 30% of that original dose is reached, then taper by 10% of that dose per week. Patients can select whether to taper long- or short-acting opioids first, and may “pause” the taper—but not increase the opioid dose—at any point.
“Taper increases mental clarity, physical energy, and emotional responsiveness,” he said. “Use early taper to build skills and confidence.”