Background information in the systematic evidence review published in Annals of Internal Medicine notes that about 10 million U.S. adults have prescriptions for long-term opioid therapy for chronic pain.
While expert guidelines recommend reducing or discontinuing long-term opioid therapy when risks outweigh the benefits, researchers from the Veterans Health Administration’s Eastern Colorado Health Care System suggest that evidence on the effects of dose reduction on patient outcomes remained unclear.
To try to remedy that, the researchers conducted a systematic review of 67 published studies to determine the effectiveness of strategies to reduce or discontinue long-term opioid therapy prescribed for chronic pain, as well as the effect of dose reduction or discontinuation on important patient outcomes. Overall, the review included 11 randomized trials and 56 observational studies that examined eight intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions.
Study quality was deemed good for three studies, fair for 13 studies, and poor for 51 studies. Study authors point out that, while many studies reported dose reduction, rates of opioid discontinuation ranged widely across interventions and the overall quality of evidence was very low. In fact, among 40 studies examining patient outcomes after dose reduction (very low overall quality of evidence), improvement was reported 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).
Data were extracted and study quality assessed by two independent reviewers using the U.S. Preventive Services Task Force quality-rating criteria.
“Very low-quality evidence suggests that several types of interventions may be effective to reduce or discontinue [long-term opioid therapy] and that pain, function, and quality of life may improve with opioid dose reduction,” study authors conclude.
Researchers caution that evidence was inadequate to assess the risks of opioid-dose reduction, recommending that multidisciplinary pain programs that incorporate behavioral interventions, such as cognitive-behavioral therapy or mindfulness meditation, should accompany opioid tapering for optimal results.
In an accompanying editorial, CDC staffers urge that any decision to discontinue or reduce long-term opioid therapy be made together with patients, adding, “These findings make it clear that before starting long-term therapy or increasing dosages, clinicians and patients need to carefully weigh the uncertain benefits of opioids for chronic pain against their increasingly clear risks.”
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