Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Ann Intern Med. 2017 Aug 1;167(3):181-191. doi: 10.7326/M17-0598. Epub 2017 Jul 11.
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Background: Expert guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT) when risks outweigh benefits, but evidence on the effect of dose reduction on patient outcomes has not been systematically reviewed.

Purpose: To synthesize studies of the effectiveness of strategies to reduce or discontinue LTOT and patient outcomes after dose reduction among adults prescribed LTOT for chronic pain.

Data Sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through April 2017; reference lists; and expert contacts.

Study Selection: Original research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain.

Data Extraction: Two independent reviewers extracted data and assessed study quality 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.

Data Synthesis: Sixty-seven studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions, were found. Study quality was good for 3 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), 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).

Limitation: Heterogeneous interventions and outcome measures; poor-quality studies with uncontrolled designs.

Conclusion: Very low quality evidence suggests 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.

Primary Funding Source: Veterans Health Administration. (PROSPERO: CRD42015020347).

Comments from MORE raters

Nurse rater

Very low quality evidence suggests 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.

Nurse rater

In light of the current 'opioid crisis' in the USA, these findings would be helpful to researchers in designing 'cleaner' studies examining the efficacy of non-opioid treatment of chronic pain syndromes. Limitations described by these authors could possibly be avoided in future studies; thereby, providing more valid evidence upon which to base interventions/recommendations.

Nurse rater

Although this systematic review shows limitations in the evidence - it is very important for prescribing providers to recognize the value of tapering patients from long-term opioids in non-malignant pain practices. This data also provides an impetus for future studies demonstrating effective pain practices that reduce and taper patients from the long-term use of opioid analgesics.

Physician rater

Table 4 presents the meat of his paper. This is not really new, but at least it's partially supported by some evidence. There is consensus that tapering may result in better outcomes.

Physician rater

Although we have been aggressively tapering opioids for our patients for several years now, this study will be useful for providers to assure reluctant patients that tapering is safe and effective.

Physician rater

Most opioids are prescribed in the primary care setting. The quality of research related to dose reduction is not stellar. Nonetheless, the article notes that multidisciplinary care and close (weekly) follow up were common in the best studies. The article also reflects on potential benefits of dose reduction and mentions opioid-induced hyperalgesia, a concept which patients often understand and find to be valid, in my experience. The editorial makes good suggestions which are applicable to the primary care setting.

Physician rater

I am actively involved in the opioid crisis here in Tennessee (Tennessee Dept of Health) where we have an epidemic of addiction and death (accidental for the most part). We are developing a data base of death and survival of overdoses with hospitals to better characterize it. Although these studies are not "great", we need to be highly visible with regard to this topic. Naloxone is an OTC here so moms, teachers, etc, can have it available for their kids/students. As the Medical Examiner here, it is unbelievable how many are dying and the demographics are likewise unbelievable (white women in their 50s???). Heroin is 7 bucks a hit. Oxy is fading`s a crisis.

Physician rater

Hugely important topic but this emphasizes that we have no idea what works. Maybe that is important.
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