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Expert guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT) when risks outweigh the benefits, but the evidence on the effect of dose reduction on patient outcomes has not been reviewed systematically.
Opioids
tapering has become challenging for both clinicians and patients in the present
scenario. A reduced opioid intake can enhance the quality and functionality of
life. The study, therefore, concentrates on finding out effective opioid
ceasing strategies.
Expert
guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT)
when risks outweigh the benefits, but the evidence on the effect of dose
reduction on patient outcomes has not been reviewed systematically. To produce
studies of the effectiveness of strategies to reduce or discontinue LTOT and
patient outcomes after dose reduction among adults prescribed LTOT for chronic
pain, MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from
inception through April 2017; reference lists; and expert contacts were
analyzed. Original research published in English that addressed dose reduction
or discontinuation of LTOT for chronic pain.
Two of
the independent reviewers extracted data and assessed the quality of the study using the U.S. Preventive Services Task
Force quality rating criteria. All authors assessed evidence quality using the
GRADE (Grading of Recommendations Assessment, Development, and Evaluation)
system. Prespecified patient outcomes were pain severity, function, quality of
life, opioid withdrawal symptoms, substance use, and adverse events.
Overall
sixty-seven studies (11 randomized trials and 56 observational studies)
examining eight intervention categories, including interdisciplinary pain
programs, buprenorphine-assisted dose reduction, and behavioural interventions,
were found. Study quality was good for three studies, fair for 13 studies, and
poor for 51 studies. Many studies reported dose reduction, but rates of opioid
discontinuation ranged widely across interventions, and the overall quality of
evidence was very low. Among 40 studies examining patient outcomes after dose
reduction (very low overall quality of evidence), an improvement was observed
in pain severity (8 of 8 fair-quality studies), function (5 of 5 fair-quality
studies), and quality of life (3 of 3 fair-quality studies). Heterogeneous
interventions and outcome measures; poor-quality studies with uncontrolled
designs were some limitations of the study.
Very
low-quality evidence suggested that several types of interventions may be
effective to reduce or discontinue LTOT and that pain, function, and quality of
life may improve with opioid dose reduction.
Annals of Internal Medicine
Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review
Joseph W. Frank et al.
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