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Fishbain DA, Pulikal A Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. Pain Med. 2018 Dec 28. pii: 5266432. doi: 10.1093/pm/pny231. (Systematic review)
Abstract

Objective: To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.

Methods: Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.

Results: No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.

Conclusions: There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.

Ratings
Discipline Area Score
Nurse 6 / 7
Physician 5 / 7
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Comments from MORE raters

Nurse rater

This is an excellent topic for me, as a prescriber, especially with the opioid crisis. I was interested to learn the results. Unfortunately, with the methodological flaws of poor study quality, including lack of controls, this information is limited and essentially not useful. I’d like to see the hypothesis addressed with a grade 1 or 2 study.

Physician rater

Interesting information. Higher quality studies are needed.
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