Proposed Opioid Reduction Guideline Reduces Depression, Pain

Nancy A. Melville

September 13, 2013

LAS VEGAS — A regimen of a slow and steady opioid tapering shows efficacy in helping patients with chronic pain taking high doses of the drugs to significantly reduce their dose, resulting in reduced pain and depression, a new study shows.

"We saw minimal withdrawal symptoms and very good outcomes, and for us, in a practice where we have several patients on very-high-dose opiates, this was ground-breaking," said lead author Rajesh Kalra, MD, medical director of the Kaiser Permanente Chronic Pain Clinic in Union City, California.

Their findings were presented here at PAINWeek 2013.

Under the guideline, patients receiving high doses of opioids have an average reduction of about 10% every 5 to 10 days until the dose is reduced to about 60%. After a reassessment, patient doses are then reduced by another 10%.

The approach was developed to avoid some of the pitfalls and severe withdrawal symptoms that can occur with more rapid tapering, Dr. Kalra explained.

"There are really no good guidelines in the literature on how to reduce opiates," he told Medscape Medical News.

"Some say that you can reduce the dose by 25% to 50% every few days, which may be unsafe for patients on high-dose opiates — for instance going from 600 to 300 mg or 300 to 150 mg."

"This may result in significant withdrawal symptoms and patients may be unwilling to pursue further dose reduction."

Chart Review

For the study, Dr. Kalra and his colleagues conducted a retrospective chart review of patients in the program between December 2009 and May 2011.

The review included 16 patients, 81% female, aged 18 to 75 years, with a diagnosis of chronic pain and an average pain score of 6 or above. The patients, who agreed to the opioid dose reduction program, were using high-dose opioid regimens, defined as 300 mg of oral morphine equivalent daily or greater.

The patients were each diagnosed with more than one chronic pain condition; the most prevalent diagnoses were low back, neck, and migraine pain. They were managed by telephone or office visits at least once monthly during their dose reduction.

During the course of about 17 weeks, the patients' daily morphine equivalent declined significantly, from an average of 945 mg to 275 mg (P < .001).

Patients' average pain scores declined from approximately 7.2 to 4.9 (P < .001), based on the Brief Pain Inventory, and depression scores also improved significantly, from an average of 13.5 to 9.5 (P < .01) based on the Patient Health Questionnaire.

Mood, walking, work, relationships, and enjoyment of life did not significantly differ after the opioid taper, but pain interference in normal daily activity decreased significantly (P < .05).

Withdrawal symptoms varied but were not severe: Three of the 16 patients reported no opioid withdrawal symptoms during the medication reduction; 6 patients said they experienced withdrawal symptoms once, and 7 patients experienced withdrawal symptoms more than once throughout the opioid tapering process.

The most common withdrawal symptoms included anxiety, sweating or chills, and muscle cramps or spasms.

Medications, including clonidine, were used to help treat withdrawal symptoms, and the patients had no significant withdrawal complications.

"We saw that not only is this guideline safe and effective for patients on high-dose opiates, but also pain, depression, and quality of life outcomes improved with less opiates versus more," Dr. Kalra said.

He added that the Chronic Pain Clinic has adopted the strategy as a dose-reduction guideline.

"This has really helped us reduce patients on high-dose opiates. We continue to practice along these lines every day and see improved outcomes in our patients after dose reduction."

Opioid dose-reduction efforts are becoming more critical amid ever-increasing concerns of the long-term use of high-dose medications, Dr. Kalra added.

"Data suggests that hundreds of thousands of patients nationwide are on potentially dangerous high-dose opiate medications. Physicians may continue these medications for several years and commonly consider dose escalation attributing this practice to opioid tolerance.

"As a result, we have patients on 300, 600, or even thousands of milligrams of morphine, oxycodone, et cetera," he said.

"The guideline we have established provides an alternative treatment option for patients on high-dose opiates. It really encourages physicians to think about what is in the patients' best interest — a dose escalation or reduction."

A "Reasonable" Approach

Pain specialist Srinivas R. Nalamachu, MD, agreed that the approach is a reasonable one for helping patients to safely reduce their opioid dosage.

"We typically taper at about 25% a week when preparing patients for clinical trials and at that rate we never see any serious withdrawal symptoms," said Dr. Nalamachu, who is president and medical director of the International Clinical Research Institute Inc and co-director of the Pain Management Institute in Overland Park, Kansas.

"So it doesn't surprise me to see that they have good results with this approach," he told Medscape Medical News.

"I think it's in line with practical medicine to make sure patients are safe when going through withdrawal. Of course patients have to be monitored, but since there are really no standardized approaches, this seems like a very safe way of doing it."

Dr. Kalra and coauthors and Dr. Nalamachu have disclosed no relevant financial relationships.

PAINWeek 2013. Abstract 45. Presented September 5, 2013.

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