- Pain Med.2015 Jun 27. doi: 10.1111/pme.12812. Clinical Implications of TaperingChronic Opioids in a Veteran Population.Harden P1 A total of 50 patient charts were included in the study. The average percent reduction of opioid doses was 46% over a 12-month period. Seventy percent of patients either experienced no change in pain or had less pain when comparing baseline to 12 months. An equal percentage of patients either had no change in the number of adjuvant medications prescribed or had more adjuvant medications prescribed when comparing baseline to 12 months.
- Clin J Pain. 2013 Sep;29(9):760-9. doi: 10.1097/AJP.0b013e31827c7cf6.
Low pain intensity after opioid withdrawal as a first step of a comprehensive pain rehabilitation program predicts long-term nonuse of opioids in chronic noncancer pain. Krumova EK1 One hundred two consecutive patients with severe CNCP despite opioid medication (mean treatment duration, 43 mo) reported pain intensity (numerical rating scale, 0 to 10), Pain Disability Index, mood (CES-D), and quality of life (Short Form 36) before, shortly, and 12 to 24 months after inpatient OW. Total opioid withdrawal (n = 78) or significant dose reduction (DR; n = 24, mean reduction, 82%) was performed after individual decision. Opioid intake 12 to 24 months later, respectively dose increase ≥ 100% (DR group), was considered relapse. T tests, multivariable analysis of variance, logistic regression.
RESULTS:
After OW current pain intensity significantly decreased on an average by 41% (6.4 ± 2.4 vs. 3.8 ± 2.5), maximal and average pain by 18% and 24%, respectively. Twelve to 24 months later 42 patients (41%) relapsed (31 of the total opioid withdrawal group, 6 of the DR group, 5 lost). Patients without later relapse showed significantly lower pain scores than the later relapsed patients already shortly after OW (5.0 ± 2.2 vs. 5.9 ± 2.1) and 12 to 24 months later (5.5 ± 2.4 vs. 6.5 ± 2.0). There was a significant relation between relapse probability and pain intensity immediately after OW.
3.
Am J Gastroenterol.2012 Sep;107(9):1426-40. doi: 10.1038/ajg.2012.142. Epub 2012 Jun 19.
Diagnosis, characterization, and 3-month outcome after detoxification of 39 patients with narcotic bowel syndrome.
Drossman DA Of the 39 patients detoxified, 89.7% met predefined criteria. Patients were mostly well educated (14.5 ± 2.3 years of school), female (92.3%), and with a variety of diagnoses (21% irritable bowel syndrome IBS/functional, 37% inflammatory bowel disease and other structural, 29% fibromyalgia and other functional somatic, or orthopedic, and 13% postoperative or other). They reported high health-care use (15.3 ± 10.1 MD visits/6 months; 6.5 ± 6.1 hospitalizations/2 years, 6.4 ± 2.0 surgeries/lifetime), and 82.1% were jobless. Despite high dosages of narcotics (total intravenous (IV) morphine equivalent 75.3 ± 78.0 mg/day), pain scores were rated severe (52.9 ± 28.8 visual analog scale (VAS); 257.1 ± 139.6 functional bowel disorder severity index (FBDSI); 17.2 ± 10.2 (McGill Pain and greater than labor or postoperative pain). Multiple symptoms were reported (n = 17.8 ± 9.2) and rated as moderate to severe. Psychosocial scores showed high catastrophizing (19.9 ± 8.6); poor daily function (Short Form-36 (SF-36) physical 28.3 ± 7.7, mental 34.3 ± 11.0; worse than tetraplegia); 28.2% were clinically depressed and 33.3% anxious (Hospital Anxiety and Depression Scale (HADS)). Detoxification was successfully completed by 89.7%; after detoxification, abdominal pain was reduced by 35% (P < 0.03) and nonabdominal pain by 42% (P < 0.01) on VAS, and catastrophizing significantly improved (P < 0.01). Responder status was met in 56.4% with 48.7% achieving a ≥ 30% reduction in pain. By 3 months after detoxification, 45.8% had returned to using narcotics. For those who remained off narcotics at 3 months, the VAS abdominal pain score was 75% lower than pretreatment when compared with those who went back on narcotics (24% lower). Successful detoxification and a good clinical response was associated with low abuse potential
4.
Pain Med.2016 Jan 11. pii: pnv079. [Epub ahead of print]
Opioid Tapering in Fibromyalgia Patients: Experience from an Interdisciplinary Pain Rehabilitation Program. Cunningham JL a pain diagnosis of fibromyalgia completing a 3-week outpatient interdisciplinary pain rehabilitation program. Opioid tapering analysis included 55 (35%) patients using daily opioids.
METHODS:
Opioid tapering was individualized to each patient based on interdisciplinary pain rehabilitation team determination. Opioid withdrawal symptoms were assessed daily, utilizing the Clinical Opioid Withdrawal Scale.
RESULTS:
Patients taking daily opioids had a morphine equivalent mean dose of 99 mg/day. Patients on < 100 mg/day were tapered off over a mean of 10 days compared with patients on > 200 mg/day over a mean of 28 days (P < 0.001). Differences in peak withdrawal symptoms were not statistically significant based on the mean equivalent dose (P = 22). Patients takingopioids for <2 years did not differ in length of tapering (P =0.63) or peak COWS score (P =0.80) compared with >2 years duration. Patients had significant improvements in pain-related measures including numeric pain scores, depression catastrophizing, health perception, interference with life, and perceived life control at program completion.
5.
J Opioid Manag. 2006 Sep-Oct;2(5):277-82.
Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. Baron MJ1,
McDonald PW.
Abstract
Opioid tolerance is a well-established phenomenon that often occurs in patients taking opioids for the treatment of chronic pain. Typically, doctors need to periodically elevate patients' opioid doses in an attempt to manage their underlying pain conditions, resulting in escalating opioid levels with only moderate to negligible improvement in pain relief. Recently, opioid-induced hyperalgesia has been recognized as a potential form of central sensitization in which a patient's pain level increases in parallel with elevation of his or her opioid dose. Here, we report a retrospective study of patients undergoing detoxification from high-dose opioids prescribed to treat an underlying chronic pain condition which had not resolved in the year prior. All patients were converted to ibuprofen to manage pain, with a subgroup treated with buprenorphine during detoxification. Self-reports for pain scores were taken at first evaluation, follow-up visits, and termination. Twenty-one of 23 patients reported a significant decrease in pain after detoxification, suggesting that high-dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of the preexisting pain condition
6.
Clin Ther. 2014 Nov 1;36(11):1555-63. doi: 10.1016/j.clinthera.2014.10.013. Epub 2014 Nov 19.
Opioid interruptions, pain, and withdrawal symptoms in nursing home residents.
Redding SE Sixty-six patients receiving opioids were followed for a mean of 10.9 months and experienced a total of 104 acute illnesses. During 64 (62%) illnesses, patients experienced any reduction in opioid dosing, with a mean (SD) dose reduction of 63.9% (29.9%). During 39 (38%) illnesses, patients experienced a significant opioid interruption. In patients with interruptions, there were statistically insignificant changes in mean (SD) pain score (difference -0.50 [2.66]; 95% CI, -3.16 to 2.16) and withdrawal score (difference -0.91 [3.12]; 95% CI, -4.03 to 2.21) after the interruption as compared with before interruption.
OTHER STUDIES:
Farm Hosp. 2014 Sep 16;38(5):411-7 Switching to another opioid while at the same time reducing opioid equivalent dosage by 37% resulted in clinical improvement in VAS (77%) and in adverse effects.
J Opioid Manag. 2012 Sep-Oct;8(5):292-8 High dose opioids in cancer patients rapid detox over 7 days due to tolerance, inefficiency, or hyperalgesia using ketoprofen or ibuprofen and oral lorazepam. Average VAS decreased from 8.3 to 3.6 after detoxification.
Am J Ther. 2006 Sep-Oct;13(5):436-44. For those taking chronic opioids for pain who receive a diagnosis of DSM4 opioid prescription medication dependence, detoxification as an inpatient reduced VAS from 5.5 to a level of 3.4 at discharge over a 5 day detox period.
J Opioid Manag Nov-Dec;11(6):481-8 A community based intervention to reduce the number of opioid prescriptions of Oxycontin to the underserved population in Florida resulted in a 75% reduction in prescribed tablets of Oxycontin, a reduction in hydrocodone and other long acting opioids, without any significant complaints from patients and no significant change in patient satisfaction
Clin J Pain 2014 Feb;30(2):93-101 80% of patients on high dose opioids (MED>50mg) that have significant side effects, reduction in pain effectiveness, reduction in perceived helpfulness, and concerns over long term use will continue high dose opioids after one year. This implies a significant chemical dependence on high dose opioids even when patients want to quit, and unless forced to reduce dosages by their physician, they will not do so.
No, I do not place these in the patient's charts- it doesn't matter if they agree or disagree. Percentage leaving my practice in the Indiana practice- 3%. They are not given any option. Percent on benzos- in Indiana, it was 15%, in Florida it is 60%, but the MED dosages are much lower- around 30mg.
