Patient-Centered Opioid Tapering in Outpatients With Chronic Pain and Long-Term Opioid Use

Background: Background: An estimated 11 million Americans were prescribed long term opioids in 2014-up to 4 percent of the entire U.S. adult population. Patients with chronic pain taking long term opioids are at higher risk for multiple health problems including more severe pain and addiction, and death from accidental overdose. Opioid related overdoses are now a leading cause of death in the U.S. Multiple national agencies have called for reduced opioid prescriptions.

Lower doses of opioids are safer for patients. Patients who take very high dose opioids for chronic pain (>200 morphine equivalent daily dose; MEDD) are at 3-fold increased risk for accidental overdose death compared to those on low doses (1). However, the primary patient concern about reducing opioids is fear of having increased pain. Indeed, evidence is lacking for how to help real-world patients with chronic pain reduce opioid use while controlling their pain.

Inpatient studies suggest that pain improves with intensive pain rehabilitation and opioid cessation (2). interdisciplinary chronic pain rehabilitation combined with opioid cessation in veterans has been associated with improved indices of psychological and physical function, as well as significantly reduced pain in those who stop opioids during the program (3). However, inpatient and intensive opioid reduction programs are costly and unavailable to most patients. Recently, researchers conducted an outpatient randomized controlled trial comparing an outpatient opioid tapering program to usual care (4). The tapering program consisted of psychiatric consultation, opioid dose tapering, and 18 weekly meetings with a physician assistant to explore motivation for tapering and learn pain self-management skills.

No studies exist to inform best practice on opioid reduction in primary care or outpatient pain clinics. There is a critical gap in knowledge on how to help community-based (primary care and pain clinic) outpatients with chronic pain actively reduce opioids while controlling pain. This project was intended to inform real-world patient care to specifically help patients with chronic pain taking long term moderate-, high-, and super high-dose opioids reduce their daily use and associated risks. The goal is to understand whether a simple, patient-centered opioid taper conducted with limited resources and no interdisciplinary supportive treatments (e.g., psychology services, physical therapy) could effectively reduce opioid dose without increasing pain.

Methods