Management of patients at risk of harms from both continuing and discontinuing their long-term opioid therapy: A qualitative study to inform the gap in clinical practice guidelines.

Background

Although long-term opioid therapy (LTOT) for chronic pain has declined, it remains common in the U.S. Providers do not have clinical practice guidelines for vulnerable LTOT patients, in whom both LTOT continuation and tapering to discontinuation pose risks of harm and in whom opioid use disorder (OUD) is absent.

Methods

To begin to meet the gap in guidelines, the study used a multiple case study approach. Five cases were constructed to systematically vary key elements of LTOT continuation and discontinuation harms among patients reporting LTOT's lack of efficacy (experience of pain and poor function). For each, treatment approaches were collected from 28 opioid safety experts identified through their participation in a national policy panel (19 were physicians) and analyzed using template analysis.

Results

For patients receiving LTOT with harms of continuation and discontinuation, experts recommended attempting a slow taper (even with a prior unsuccessful taper, possibly with adjuvant medications to manage withdrawal) and not maintaining opioid therapy. Experts considered switching to buprenorphine, especially if the patient had aberrant behaviors. They also considered adding non-opioid pain therapies (especially re-trying such therapies if they were unhelpful before) and engaging in shared decisionmaking, although with little consensus on specific approaches. Some experts would address co-occurring conditions related to patient safety (alcohol use, mental health symptoms, opioid side effects). Few experts referenced assessing or addressing OUD or overdose risk. In quantitative data, 36% of experts agreed LTOT is beneficial, 36% agreed most LTOT patients should be discontinued, and 57% agreed patients experience harm from tapering and from discontinuation.

Discussion

Evidence is needed to build on and test these experts' recommendations to attempt tapering and add non-opioid pain therapies for patients reporting harms of continued LTOT who may experience harms from tapering. Such evidence informs the development of clinical practice guidelines that provide comprehensive protocols to support the safety and functioning of this group of patients.

References:

• IQVIA Institute. The use of medicines in the US 2023. Durham, NC: IQVIA; 2023.
• Ukhanova M, Voss RW, Marino M, Huguet N, Bailey SR, Hartung DM, et al. Chronic overlapping pain conditions and long‐term opioid treatment. Am J Manag Care. 2023;29(5):233–239. https://doi.org/10.37765/ajmc.2023.89356
• Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. ASIPP guidelines for responsible opioid prescribing in chronic non‐cancer pain: part I—evidence assessment. Pain Physician. 2012;15(3 Suppl):S1–S65.
• Binswanger IA, Glanz JM, Faul M, Shoup JA, Quintana LAM, Lyden J, et al. The association between opioid discontinuation and heroin use. Drug Alcohol Depend. 2020;217:108248. https://doi.org/10.1016/j.drugalcdep.2020.108248
• Timko C, Kroenke K, Nevedal A, Lor MC, Oliva E, Drexler K, et al. Development and field testing of primary care screening tools for harms of long‐term opioid therapy continuation and tapering to discontinuation. BMJ Open. 2021;11(10):e053524. https://doi.org/10.1136/bmjopen‐2021‐053524