Education, Slow Approach Help Patients Successfully Taper Opioids

Pauline Anderson

April 30, 2018

VANCOUVER, British Columbia — New research challenges the perception that patients with chronic pain receiving long-term opioid therapy don't want to get off these drugs, or can't do so without experiencing increased pain.

Patients who completed a 4-month tapering program cut their opioid dose in half — and some came off opioids completely — with no increased pain.

The study showed that many patients with chronic pain are keen to reduce their opioids, but it often takes more than a few months to achieve this.

"This suggests that current tapering algorithms may be too aggressive," author Beth Darnall, PhD, clinical professor, Department of Anesthesiology and Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University, California, told delegates attending the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Following decades of overprescribing opioids, which has led to unintentional overdoses and deaths, clinicians are being urged to "de-prescribe" these drugs, said Darnall.

Fear a Major Barrier

One of the biggest fears of patients receiving opioids is increased pain if they go off these drugs, she said.

"This fear is standing as a barrier to opioid reduction; it's not the only barrier, but it's an important one to consider."

Research shows that a multidisciplinary program can reduce opioid use among inpatient veterans without increasing their pain. The investigators wanted to know if this was the case for "everyday, real-world patients in the community setting," Darnall said.

A common "misperception" is that reducing opioid doses in the outpatient setting requires "a lot of resources similar to the inpatient setting," she said.

Other misperceptions, she added, are that efforts to reduce opioids in long-time users, or those taking high doses of the drugs, are unlikely to be successful.

There's not much in the way of guidance for community-based opioid tapering. Guidelines that do exist "are perhaps too aggressive and have contributed to failed tapers, withdrawal symptoms and perpetuating the misperception that reducing opioids leads to increased pain in the outpatient setting," said Darnall.

Of the 110 patients who were invited to participate in the program, 82% expressed interest. A total of 68 patients actually enrolled and 51 remained in the program.

Participants had an average age of 52 years and 55% were female. They had been receiving opioids for a mean of 6 years and had moderate pain intensity.

There were no differences between those who remained in the study and those who dropped out, except that those who dropped out were more likely to have higher levels of depressive symptoms.

Patients in the program received a self-help book and education about the benefits of reducing opioids. They partnered with their physician to develop a tailored program to taper opioids.

"It's important to note that the goal was not no opioids; the goal was to get as low as possible in as comfortable a manner as possible, over the 4-month study period," said Darnall.

She emphasized that the program was voluntary and that the study included a "mixed etiology" of chronic pain sufferers. "Anyone taking opioids was invited to be part of this project," she said.

Keys to Success

At baseline and at 4 months, patients completed online assessments and provided data on demographic characteristics, opioid use, pain, and psychosocial measures.

Researchers converted opioid doses to a standard morphine equivalent daily dose (MEDD).

Among the 51 completers, the baseline median MEDD of 288 was reduced almost by half to 150 (P = .002) at the 4-month follow-up.

"Patients who remained in the program successfully reduced their opioid dose in a statistically significant and clinically meaningful way," said Darnall.

"Sixteen patients reduced their opioid dose to below 90 mg daily, and four patients tapered off the drug entirely."

Pain intensity (P = .29) and pain interference (P = .44) did not increase with opioid reduction. 

The investigators also found that the initial opioid dose did not predict taper response.

"Again, this challenges a common perception that patients on moderate, high, or very high doses of opioids are unlikely to succeed in reducing opioids on an outpatient basis," said Darnall.

The "key" to the success of the program is providing patients with education and tapering opioids slowly, making sure that patients "are in control" and can "pause" or "drop out" at any time, she said.

She noted that while the opioid dose decreased, not many of the psychosocial variables "budged."

Darnell said she has secured funding to carry out a trial of 1300 patients in four states that will compare two evidence-based psycho-behavioral treatments "within the context of voluntary opioid tailoring" to see if such supports will further improve taper response, she said.

"Paradigm Shift"

Commenting on the study for Medscape Medical News, James C. Watson, MD, associate professor, and vice chair, Department of Neurology, Mayo Clinic, Rochester, Minnesota, who is board certified in pain medicine as well as neurology, clinical neurophysiology, and neuromuscular disease, said the study is important in the context of the current environment, where opioid use is being discouraged.

He referred to the "paradigm shift" in the United States to greater recognition of the adverse effects of opioids, including respiratory depression and death.

At the same time, new guidelines have "redefined" the appropriate role of opioids, and some insurance companies have put caps on opioid prescriptions, said Watson.

With this background, it's important that an opioid tapering program can effectively lower drug doses — in some cases cutting it in half —  "without worsening pain and without worsening comorbid conditions, including depression and anxiety," said Watson.

"The study is also important because it was done in a community setting and took all comers, so it's applicable to real-world practice," he said.

The authors and Watson have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract 190. Presented Friday April 27, 2018.

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