Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
BACKGROUND:
Approximately 10 million U.S. adults are prescribed long-term opioid therapy (LTOT) for chronic pain despite inadequate evidence of long-term benefit and growing evidence of harms. Investigators conducting this systematic review examined the evidence on the effectiveness of strategies to reduce or discontinue LTOT prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Conducting literature searches in multiple databases from inception through April 19, 2017, investigators identified 67 studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions.
FINDINGS:
- This systematic review identified multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low.
- Common themes across intervention types can provide insight into the program components that may provide effective support of opioid tapering. In the 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies.
- Investigators identified 40 studies that assessed the effect of dose reduction or discontinuation of LTOT on patient outcomes, however, the overall quality of the evidence was very low.
- The fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies, and quality of life (3/3 studies) following opioid dose reduction.
- Few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
IMPLICATIONS:
- To support Veterans during dose reduction or discontinuation of LTOT, facilities should seek to expand access to existing multidisciplinary pain programs, when available, or team-based approaches that incorporate treatment coordination and self-management (e.g., patient-centered medical homes, primary care-mental health integration).
- Given inadequate evidence on the risks of opioid tapering, study investigators suggest caution and close monitoring is warranted during and after opioid tapering; in addition, consideration of overdose prevention strategies (i.e., naloxone) may be prudent.
LIMITATIONS:
- There was substantial heterogeneity in measures of opioid dose reduction and of patient outcomes, as well as within clinically relevant domains of intervention components.
AUTHOR/FUNDING INFORMATION:
This study was funded by VA HSR&D's Quality Enhancement Research Initiative (QUERI). Dr. Frank is with HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care; Dr. Lovejoy is part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC); and Dr. Becker is with HSR&D's Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center.
Frank J, Lovejoy T, Becker W, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Annals of Internal Medicine. July 18, 2017;e-pub ahead of print.
