[Full text] Impact of opioid dose reduction on individuals with chronic pain: results of an online survey | JPR – by Twillman RK, Hemmenway N, Passik SD, Thompson CA, Shrum M, DeGeorge MK – Nov 2018

Background: In 2016, the Centers for Disease Control and Prevention (CDC) released a guideline on opioid prescribing for primary care physicians. Patients with chronic pain receiving long-term opioid therapy were surveyed to assess the incidence and impact of opioid dose reduction following this guideline’s promulgation.

Methods:

Members of an advocacy organization for people with chronic pain were invited to participate in a 16-item, anonymous, online survey conducted in September/October 2017.

Eligibility requirements included current treatment of ≥7 months’ duration for chronic pain with the same extended-release (ER)/long-acting (LA) opioid.

The final sample consisted of respondents who reported being on the same ER/LA opioid for ≥1 year and excluded respondents whose

1) ER/LA opioid dose increased;

2) ER/LA opioid dose decreased and immediate-release (IR) opioid dose increased; and

3) ER/LA opioid dose was unchanged and IR opioid dose was changed.

Survey results were analyzed using z-test to ascertain differences between proportion of responses for ER/LA opioid dose decreased vs dose unchanged groups.

Results:

Of the 511 eligible respondents, 362 respondents were included in the final sample.

In the final sample, the subgroup with decreased ER/LA opioid dose (n=149) was significantly more likely (P≤ 0.05) than those who reported no dose change (n=213) to rate their condition as “worse” for

level of pain (73.2 vs 33.3%),

level of function (67.8 vs 31.5%),

mental health (64.4 vs 32.9%),

ability to work (62.9% of 97 respondents vs 33.8% of 145 respondents), and

interpersonal relationships (48.3 vs 25.8%)

during the previous 6 months.

Conclusion:

In this Internet-based survey of people with chronic pain, reduction of ER/LA opioid dose was associated with reduced pain control and diminished function.

These results indicate a need for further guidance on how to apply the CDC guideline to patients with chronic pain who are stable on long-term opioid therapy.

Discussion

In this Internet-based survey of people with chronic pain, more than 90% of the study participants reported receiving chronic pain treatment directed by a medical professional for longer than 1 year.

One-third of respondents reported a decrease in ER/LA opioid dose during the previous 6 months; the decrease in medication dosing was associated with reduced pain control and negative impact on function, interpersonal relationships, and mental health.

Respondents whose ER/LA opioid dose was decreased were more likely to report increases in adverse events associated with opioid withdrawal compared with those whose dose was unchanged.

The findings of the current survey are consistent with those reported by the Pain News Network following its survey of patients (N=3,108) and health care providers (N=278), which was conducted in collaboration with the International Pain Foundation between February 15 and March 11, 2017 (following the CDC dosing guideline release).

Approximately 48% of patients reported a decrease in opioid dose,

23% reported the discontinuation of opioid medication, and 84% reported worsened pain.

More than one-half (59%) of health care providers reported that a pharmacy had refused to fill an opioid prescription, and

57% reported that an insurance company had refused to pay for a pain treatment the provider thought the patient should have.

…unintended consequences of the opioid dose reduction guidelines may include not only barriers to initial prescribing but also disruption of care in patients taking stable ER/LA opioid doses.

Such an outcome may violate the core tenets of opioid prescribing – including those in the CDC guideline itself – which mandates patient-centric care.