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Please read this study and write a summary of 200-300 words. I have
attached the study. Please no plagiarism this article is on nursing specific opiate guidelines. Please use good English.
Tapering Long-term Opioid Therapy in
Chronic Noncancer Pain: Evidence and
Recommendations for Everyday Practice
Chantal Berna, MD, PhD; Ronald J. Kulich, PhD; and James P. Rathmell, MD
CME Activity
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ä
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Learning Objectives:
On completion of this article, you should be able to
(1) appropriately identify circumstances when tapering chronic opioid ther-
apy (COT) in patients with chronic noncancer pain should be considered;
(2) recognize withdrawal symptoms during a COT taper, classify them for
severity, and choose an adequate treatment; (3) apply strategies for
medico-legal risk management during a COT taper, including using an opioid
taper agreement.
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nancial relationship(s) with industry. Dr Berna
received salary support in part through an unrestricted educational grant from
Purdue Pharmaand inpart froman Advanced Postdoc Mobilitygrant of the Swiss
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or in
fl
uence into the conception, design, or preparation of this manuscript.
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Abstract
Increasing concern about the risks and limited evidence supporting the therapeutic bene
f
t of long-term opioid
therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids. In
additiontoovert addiction or diversion,the presence ofadverse effects, diminishinganalgesia,reducedfunction
and quality of life, or the absence of progress toward functional goals can justify an attempt at weaning patients
from long-term opioid therapy. However, discontinuing opioid therapy is often hindered by patients
’
psy-
chiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers. The aim
of this article is to review the existing literature and formulate recommendations for practitioners aiming to
discontinue long-term opioid therapy. Speci
f
cally, this review aims to answer the following questions: What is
an optimal opioid tapering regimen? How can the risks involved in a taper be managed? What are the alter-
natives to an opioid taper? A PubMed literature search was conducted using the keywords
chronic pain
com-
bined with
opioid withdrawal
,
taper
,
wean
and
detoxi
f
cation
. Six hundred ninety-
f
ve documents were identi
f
ed
and screened; 117 were deemed directly relevant and are included. On the base of this literature review, this
article proposes evidence-based recommendations and expert-based suggestions for clinical practice.
Furthermore, areas of lack of evidence are identi
f
ed, providing opportunities for further research.
ª
2015 Mayo Foundation for Medical Education and Research
n
Mayo Clin Proc. 2015;90(6):828-842
From the Department of
Anesthesia, Critical Care and
Pain Medicine, Massachusetts
General Hospital and Harvard
Medical School (C.B., R.J.K.,
J.P.R.), and Tufts University
School of Dental Medicine
(R.J.K.), Boston, MA.
SYMPOSIUM ON PAIN MEDICINE
828
Mayo Clin Proc.
n
June 2015;90(6):828-842
n
http://dx.doi.org/10.1016/j.mayocp.2015.04.003
www.mayoclinicproceedings.org
n
ª
2015 Mayo Foundation for Medical Education and Research
R
ecent systematic reviews and meta-
analyses suggest that long-term opioid
treatment for chronic noncancer pain
(CNCP) is supported by limited evidence.
1-10
First, the published studies of long-term opioid
treatment for CNCP present the following
issues, as reviewed in a recent Cochrane
meta-analysis: few randomized clinical trials, a
high discontinuation rate (up to 30%) of opioid
therapy in the observed populations because of
adverse effects or insuf
f
cient pain relief, and a
relatively short observational period (6-48
months; mean, 15.15 months).
5
Second, the re-
sults of these trials provide only weak evidence
that long-term opioid therapy can provide clini-
cally signi
f
cant pain relief and fail to provide any
conclusive evidence for improved quality of life
or function.
5
Amongthe 4.3 millionAmericanpatients pre-
scribed opioids,
11
often for CNCP, many present
an unfavorable risk-bene
f
t ratio for this treat-
ment.
12
Although noting situations when a taper
might be necessary, current guidelines regarding
long-term opioid treatment in CNCP, whether
published by multidisciplinary expert groups
suchas theAmericanPain Society andthe Amer-
ican Academy of Pain Medicine, or regulating
organizations such as the Federation of State
Medical Board, focus on how to prescribe safely
and effectively but do not provide practical
adviceonopioidtreatmentdiscontinuation.
13,14
The burden of tapering long-term opioid treat-
ment often falls on community pain practices
and individual physician practices, where re-
sources are relatively limited, rather than tertiary
centers. Yet, practitioners face patients present-
ing with psychiatric comorbidities, such as per-
sonality disorders, somatic symptom disorder,
substance use disorder (SUD),
15-17
and depres-
sion,
18
as well as poor coping abilities.
19
The available literature was reviewed to
formulate evidence-based recommendations
on tapering long-term opioid treatment
in CNCP, speci
f
cally aiming to answer the
following questions: What is an optimal
opioid tapering regimen? How can the risks
involved in a taper be managed? What are
the alternatives to an opioid taper?
INDICATIONS FOR TAPERING OF
LONG-TERM OPIOID TREATMENT
Adverse effects often outweigh the bene
f
ts of
long-term opioid treatment: sedation, decreased
concentration and memory, drowsiness, changes
in mood, constipation, dry mouth, abdominal
pain, nausea, hormonal changes with conse-
quences such as sexual dysfunction, and osteo-
penia may limit treatment tolerability.
4,5
The
bene
f
ts of long-term opioid treatment can
also be questioned when a patient reports inad-
equate analgesia despite high doses (tolerance),
reduced function, quality of life, or absence of
progress toward therapeutic goals.
13
Table 1
presents the indications for tapering long-term
opioid treatment.
14,20
Tapering might also be
considered for patients planning elective sur-
gery. According to a retrospective trial, patients
with CNCP undergoing long-term opioid treat-
ment (N
¼
30) experience more postoperative
pain than controls without long-term opioid
treatment (N
¼
25).
21
However, there is no
research yet on the effect of preoperative tapering
on postsurgical pain outcomes.
Diversion and addiction are alarming but
relatively uncommon considering the number
of
patients
undergoing
long-term
opioid
treatment.
7,22-24
Addiction (ie, SUD or more
speci
f
cally opioid use disorder [OUD]) is a psy-
chiatric diagnosis that involves use despite nega-
tive consequences and/or loss of control over
use, compulsions, and cravings.
25
Among pa-
tients with chronic pain, adherence vs abuse
can be seen on a spectrum,
12
and OUD is a dif
f
-
cult diagnosis to establish with certainty, justi-
fying involvement of an addiction specialist for
initial evaluation and follow-up.
26,27
Although
the current review aims to focus on patients
with CNCP, patients with cancer pain may
develop similar dif
f
culties related to opioid
use.
28
Diversion (ie, any act that results in
another individual receiving the medication
than the one it was prescribed to) is a legal issue
discussed further below.
CENTRAL ISSUES DURING TAPERING OF
LONG-TERM OPIOID TREATMENT
Short-term Risks
Withdrawal Syndrome.
Opioid withdrawal
syndrome is characterized by signs and symp-
toms of sympathetic stimulation (due to
decreased sympathetic antagonism by opioids),
which has been well described in patients with
SUD: anxiety, hypertension, tachycardia, rest-
lessness, mydriasis, diaphoresis, tremor, piloer-
ection, nausea, abdominal cramps, diarrhea,
TAPERING OPIOID THERAPY FOR NONCANCER PAIN
Mayo Clin Proc.
n
June 2015;90(6):828-842
n
http://dx.doi.org/10.1016/j.mayocp.2015.04.003
www.mayoclinicproceedings.org
829
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