Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis

Abstract Background There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently, there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use. Methods The current study details a retrospective review of 240 patients with chronic pain and LTOT presenting for treatment at a specialty opioid refill clinic. Patients first were initiated on an outpatient taper or, if taper was not tolerated, transitioned to buprenorphine. This study analyzes potential predictors of successful tapering, successful buprenorphine transition, or failure to complete either intervention and the effects of this clinical approach on pain intensity scores. Results One hundred seven patients (44.6%) successfully tapered their opioid medications under the Centers for Disease Control and Prevention guideline target dose (90 mg morphine-equianalgesic dosage), 45 patients (18.8%) were successfully transitioned to buprenorphine, and 88 patients (36.6%) dropped out of treatment: 11 patients during taper, eight during buprenorphine transition, and 69 before initiating either treatment. Conclusions. Higher initial doses of opioids predicted a higher likelihood of requiring buprenorphine transition, and a co-occurring benzodiazepine or z-drug prescription predicted a greater likelihood of dropout from both interventions. Patterns of change in pain intensity according to treatment were mixed: among successfully tapered patients, 52.8% reported greater pain and 23.6% reported reduced pain, whereas 41.8% reported increased pain intensity and 48.8% reported decreased pain after buprenorphine transition. Further research is needed on predictors of treatment retention and dropout, as well as factors that may mitigate elevated pain scores after reduction of opioid dosing.

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Opioid Misuse and Addiction Among Patients With Chronic Pain

Pain Care Essentials ◽

10.1093/med/9780199768912.003.0021 ◽

2019 ◽

pp. 339-354

Author(s):

Marc O. Martel ◽

Robert N. Jamison

Keyword(s):

Chronic Pain ◽

Opioid Therapy ◽

Screening Tools ◽

Prescription Opioid ◽

Opioid Misuse ◽

Chronic Noncancer Pain ◽

Medication Misuse ◽

Opioid Medications ◽

Noncancer Pain

Chapter 20 provides an introduction to understanding the prevalence and risk factors as well as screening tools for assessing opioid misuse and addiction in patients with chronic pain. In the era of the opioid epidemic in North America and beyond, the use of prescription opioid medications to help improve function in chronic noncancer pain is frequently debated. Out of fear of iatrogenic addiction, litigation, and/or potential medication misuse, some clinicians are refusing to prescribe opioids for chronic pain. Evidence indicates that rates of opioid misuse and addiction are fairly high among chronic pain patients prescribed long-term opioid therapy, but there is consensus that opioids can be safe and effective for carefully selected and monitored patients.

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Classification of Patients for whom benefit no longer outweighs harm of long-term opioid therapy: Protocol for a Delphi study (Preprint)

10.2196/preprints.33310 ◽

2021 ◽

Author(s):

Raymond Van Cleve ◽

Sara Edmond ◽

Jennifer Snow ◽

Anne Black ◽

Jamie Pommeranz ◽

...

Keyword(s):

Chronic Pain ◽

Delphi Study ◽

Opioid Therapy ◽

High Dose ◽

Veterans Health ◽

Health Administration ◽

Opioid Dependency ◽

Modified Delphi ◽

Modified Delphi Technique

UNSTRUCTURED Introduction: Patients with chronic pain who have been prescribed long term opioid therapies often come to a point where the benefits of their therapy are out weighted by the risks associated with taking such a high dose of opioid medication. These patients need to taper off their opioid therapy while simultaneously treating their chronic pain. At the 2019 Veterans' Health Administration State of the Art Conference, there was an acknowledgment of a lack of clinical guidance with regards to treating this subset of patients. Some of the participants believed clinicians and patients would both benefit from a new diagnostic entity describing this situation where patients needed to have their opioid dependency and chronic pain simultaneously treated. Given the ability of a Delphi method to synthesize input from a broad range of experts, we felt this technique could be used to determine if a new diagnostic entity was needed and what the criteria of the diagnostic entity would be. Methods: This would be a modified Delphi technique involving three rounds. The first round would be a series of open ended questions asking about the necessity of this diagnostic entity, how this condition is different from OUD, and what it's possible diagnostic criteria would be. After synthesizing the responses collected, a second round would be conducted to ask participants to rate the different responses offered by their peers. These ratings would be collected, analyzed, and would generate a final potential definition for this clinical phenomena. In the third round we would circulate this definition and would hopefully gain consensus. Dissemination: This protocol has been approved by the Internal Review Board at the Connecticut VA and the study is in process. We hope that other researchers can use this protocol to conduct similar studies and further explore how patients with concurrent chronic pain and opioid dependency can be best served.

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Opioid crisis in primary care? An audit of high-dose opioid prescribing at Bangholm GP Practice

British Journal of General Practice ◽

10.3399/bjgp20x711581 ◽

2020 ◽

Vol 70 (suppl 1) ◽

pp. bjgp20X711581

Author(s):

Charlotte Greene ◽

Alice Pearson

Keyword(s):

Chronic Pain ◽

Back Pain ◽

Practice Guidelines ◽

Best Practice ◽

Evidence Base ◽

High Dose ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Best Practice Guidelines

BackgroundOpioids are effective analgesics for acute and palliative pain, but there is no evidence base for long-term pain relief. They also carry considerable risks such as overdose and dependence. Despite this, they are increasingly prescribed for chronic pain. In the UK, opioid prescribing more than doubled between 1998 and 2018.AimAn audit at Bangholm GP Practice to understand the scale of high-strength opioid prescribing. The aim of the audit was to find out if indications, length of prescription, discussion, and documentation at initial consultation and review process were consistent with best-practice guidelines.MethodA search on Scottish Therapeutics Utility for patients prescribed an average daily dose of opioid equivalent ≥50 mg morphine between 1 July 2019 and 1 October 2019, excluding methadone, cancer pain, or palliative prescriptions. The Faculty of Pain Medicine’s best-practice guidelines were used.ResultsDemographics: 60 patients (37 females), average age 62, 28% registered with repeat opioid prescription, 38% comorbid depression. Length of prescription: average 6 years, 57% >5 years, 22% >10 years. Opioid: 52% tramadol, 23% on two opioids. Indications: back pain (42%), osteoarthritis (12%), fibromyalgia (10%). Initial consultation: 7% agreed outcomes, 35% follow-up documented. Review: 56% 4-week, 70% past year.ConclusionOpioid prescribing guidelines are not followed. The significant issues are: long-term prescriptions for chronic pain, especially back pain; new patients registering with repeat prescriptions; and no outcomes of treatment agreed, a crucial message is the goal is pain management rather than relief. Changes have been introduced at the practice: a patient information sheet, compulsory 1-month review for new patients on opioids, and in-surgery pain referrals.

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Racial and Ethnic Disparities in the Treatment of Chronic Pain

Pain Medicine ◽

10.1093/pm/pnaa427 ◽

2020 ◽

Author(s):

Mary E Morales ◽

R Jason Yong

Keyword(s):

Chronic Pain ◽

Racial Differences ◽

Current Literature ◽

Ethnic Disparities ◽

The United States ◽

Cross Sectional ◽

Effective Interventions ◽

Sociodemographic Profile

Abstract Objective To summarize the current literature on disparities in the treatment of chronic pain. Methods We focused on studies conducted in the United States and published from 2000 and onward. Studies of cross-sectional, longitudinal, and interventional designs were included. Results A review of the current literature revealed that an adverse association between non-White race and treatment of chronic pain is well supported. Studies have also shown that racial differences exist in the long-term monitoring for opioid misuse among patients suffering from chronic pain. In addition, a patient’s sociodemographic profile appears to influence the relationship between chronic pain and quality of life. Results from interventional studies were mixed. Conclusions Disparities exist within the treatment of chronic pain. Currently, it is unclear how to best combat these disparities. Further work is needed to understand why disparities exist and to identify points in patients’ treatment when they are most vulnerable to unequal care. Such work will help guide the development and implementation of effective interventions.

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Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2018.10.493 ◽

2019 ◽

Vol 57 (1) ◽

pp. 20-27 ◽

Cited By ~ 16

Author(s):

Jessica S. Merlin ◽

Kanan Patel ◽

Nicole Thompson ◽

Jennifer Kapo ◽

Frank Keefe ◽

...

Keyword(s):

Chronic Pain ◽

Palliative Care ◽

Cancer Survivors ◽

National Survey ◽

Opioid Therapy ◽

Care Providers

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Poster 530 Nutrition and Eating Behavior in Patients with Chronic Pain Receiving Long-Term Opioid Therapy

PM&R ◽

10.1016/j.pmrj.2014.08.401 ◽

2014 ◽

Vol 6 (9) ◽

pp. S181

Author(s):

Joseph Walker ◽

Alec L. Meleger ◽

Cameron K. Froude

Keyword(s):

Chronic Pain ◽

Eating Behavior ◽

Opioid Therapy

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Long-Term Opioid Therapy for Chronic Pain

Annals of Internal Medicine ◽

10.7326/l15-5109-2 ◽

2015 ◽

Vol 163 (2) ◽

pp. 147

Author(s):

J. Walden Retan

Keyword(s):

Chronic Pain ◽

Opioid Therapy

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Monitoring outcomes during long-term opioid therapy for noncancer pain: Results with the Pain Assessment and Documentation Tool

Journal of Opioid Management ◽

10.5055/jom.2005.0055 ◽

2005 ◽

Vol 1 (5) ◽

pp. 257 ◽

Cited By ~ 53

Author(s):

Steven D. Passik, PhD ◽

Kenneth L. Kirsh, PhD ◽

Laurie Whitcomb, MA ◽

Jeffrey R. Schein, PhD, MPH ◽

Mitchell A. Kaplan, PhD ◽

...

Keyword(s):

Chronic Pain ◽

Side Effects ◽

Pain Assessment ◽

The United States ◽

Opioid Therapy ◽

Chronic Pain Patients ◽

Noncancer Pain ◽

Documentation Tool ◽

Pain Patients

The increasingly common practice of long-term opioid therapy for chronic noncancer pain must be guided by ongoing assessment of four types of outcomes: pain relief, function, side effects, and drug-related behaviors. Our objective was to gather initial pilot data on the clinical application of a specialized chart note, the Pain Assessment and Documentation Tool (PADT), which was developed and tested with 27 physicians. This pilot test provided the means to collect cross-sectional outcome data on a large sample of opioid-treated chronic pain patients. Each of the physician volunteers (located in a variety of settings across the United States) completed the PADT for a convenience sample of personally treated chronic pain patients who had received at least three months of opioid therapy. Completion of the PADT required a clinical interview, review of the medical chart, and direct clinical observation. Data from the PADTs were collated and analyzed. The results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all four relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality was generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common but viewed as an indicator of a problem (i.e., addiction or diversion) in only approximately 10 percent of cases. Using the PADT, physician ratings can be developed in four domains. In this sample, outcomes suggested that opioid therapy provided meaningful analgesia.

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