The work by Henry et al, addresses a complex clinical scenario that has become an important part of medical practice in a patient-centered, comprehensive way. While the design of the study is necessarily subjective and may suffer selection bias as the authors note, patient perspectives related to chronic pain, opioid use and tapering are critical in guiding practice.
The most important consideration when considering an opioid taper is assessment of the risks and benefits. Previously reported work has focused on the demonstrated risk of higher dose opioid therapy, particularly more than 90 morphine milligram equivalents a day. However, evidence for benefit of long-term higher dose opioid therapy for those with severe, chronic pain is lacking, which is not the same as lack of benefit. At the same time, the incidence of risks associated with rapid tapering, abandonment and chronic poorly controlled pain including transition to illicit opioids, reduced functionality, depression and suicide is relatively poorly understood.
Given these competing factors, individual assessment of functionality, tolerance, adverse effects and risks must be considered when contemplating a taper from established, high-dose opioid regimens, particularly for the vast majority of patients who have not demonstrated misuse or addictive behavior. Frequently, tolerance and dependence, which are anticipated, predictable outcomes of long-term opioid therapy, are erroneously conflated with misuse and addiction which leads to real and perceived stigma among patients on chronic opioid therapy. When tapering is performed, anticipation of withdrawal symptoms, both physical and psychological, should be expected, ameliorated and frequently assessed through open, honest and empathic communication between patient and physician.
The association of markedly increased opioid prescribing with increased opioid misuse and addiction leading to an epidemic of overdose deaths has resulted in attempts to reduce opioid prescribing through interventions including guideline development and provider clinical decision support tool implementation. Ideally, these tools will be implemented as part of a coordinated plan with the focus solely on the health and well-being of each individual patient, recognizing the significant variability in social, physiological and mental health factors that contribute to pain and risk of substance use disorder. Henry and colleagues’ work sought to provide a sample of the diverse nature of patient experiences with pain and pain management with a core message that open and honest communication with patients regarding their health care and provider focus on individual health and well-being rather than arbitrary application of uniform standards and recommendations is paramount. The need to focus on individual patient goals and function is typically recognized in published guidelines, but often overlooked when applied to regulatory standards or predefined norms of practice. Great caution should be taken with translation of guidelines, meant as general guidance for many but not all patients, into legislative, insurer, or practice-based mandates. These concerns were clearly reflected by the patients who participated in Henry et al’s study.
These researchers have collected and summarized patient experiences with opioid therapy and tapering. Minimizing excessive opioid exposure while optimizing nonopioid and nonpharmacologic treatment strategies for pain are appropriate goals. This work highlights the need for communication of risks, benefits, goals, fears, and expectations among health care providers and patients to achieve the best possible combination of function, pain relief, and safety.
Michael Lynch, MD
Medical Director, Pittsburgh Poison Center at University of Pittsburgh Medical Center
Assistant Professor, department of emergency medicine, University of Pittsburgh School of Medicine
Disclosures: Lynch reports no relevant financial disclosures.