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Management of patients at risk of harms from both continuing and discontinuing their long‐term opioid therapy: A qualitative study to inform the gap in clinical practice guidelines.

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Title: Management of patients at risk of harms from both continuing and discontinuing their long‐term opioid therapy: A qualitative study to inform the gap in clinical practice guidelines.
Authors: Timko, Christine, Lor, Mai Chee, Kertesz, Stefan, Kroenke, Kurt, Macia, Kathryn, Nevedal, Andrea, Hoggatt, Katherine J.
Source: Pain Practice. Jan2025, Vol. 25 Issue 1, p1-12. 12p.
Subjects: Risk assessment, Medical protocols, Chronic pain, Qualitative research, Drug therapy, Primary health care, Decision making in clinical medicine, Thematic analysis, Opioid analgesics, Drug efficacy, Pain management, Case studies, Sociodemographic factors, Drug abusers
Abstract: Background: Although long‐term opioid therapy (LTOT) for chronic pain has declined, it remains common in the U.S. Providers do not have clinical practice guidelines for vulnerable LTOT patients, in whom both LTOT continuation and tapering to discontinuation pose risks of harm and in whom opioid use disorder (OUD) is absent. Methods: To begin to meet the gap in guidelines, the study used a multiple case study approach. Five cases were constructed to systematically vary key elements of LTOT continuation and discontinuation harms among patients reporting LTOT's lack of efficacy (experience of pain and poor function). For each, treatment approaches were collected from 28 opioid safety experts identified through their participation in a national policy panel (19 were physicians) and analyzed using template analysis. Results: For patients receiving LTOT with harms of continuation and discontinuation, experts recommended attempting a slow taper (even with a prior unsuccessful taper, possibly with adjuvant medications to manage withdrawal) and not maintaining opioid therapy. Experts considered switching to buprenorphine, especially if the patient had aberrant behaviors. They also considered adding non‐opioid pain therapies (especially re‐trying such therapies if they were unhelpful before) and engaging in shared decisionmaking, although with little consensus on specific approaches. Some experts would address co‐occurring conditions related to patient safety (alcohol use, mental health symptoms, opioid side effects). Few experts referenced assessing or addressing OUD or overdose risk. In quantitative data, 36% of experts agreed LTOT is beneficial, 36% agreed most LTOT patients should be discontinued, and 57% agreed patients experience harm from tapering and from discontinuation. Discussion: Evidence is needed to build on and test these experts' recommendations to attempt tapering and add non‐opioid pain therapies for patients reporting harms of continued LTOT who may experience harms from tapering. Such evidence informs the development of clinical practice guidelines that provide comprehensive protocols to support the safety and functioning of this group of patients. [ABSTRACT FROM AUTHOR]
Copyright of Pain Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites without the copyright holder's express written permission. Additionally, content may not be used with any artificial intelligence tools or machine learning technologies. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
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  Data: Management of patients at risk of harms from both continuing and discontinuing their long‐term opioid therapy: A qualitative study to inform the gap in clinical practice guidelines.
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  Data: Background: Although long‐term opioid therapy (LTOT) for chronic pain has declined, it remains common in the U.S. Providers do not have clinical practice guidelines for vulnerable LTOT patients, in whom both LTOT continuation and tapering to discontinuation pose risks of harm and in whom opioid use disorder (OUD) is absent. Methods: To begin to meet the gap in guidelines, the study used a multiple case study approach. Five cases were constructed to systematically vary key elements of LTOT continuation and discontinuation harms among patients reporting LTOT's lack of efficacy (experience of pain and poor function). For each, treatment approaches were collected from 28 opioid safety experts identified through their participation in a national policy panel (19 were physicians) and analyzed using template analysis. Results: For patients receiving LTOT with harms of continuation and discontinuation, experts recommended attempting a slow taper (even with a prior unsuccessful taper, possibly with adjuvant medications to manage withdrawal) and not maintaining opioid therapy. Experts considered switching to buprenorphine, especially if the patient had aberrant behaviors. They also considered adding non‐opioid pain therapies (especially re‐trying such therapies if they were unhelpful before) and engaging in shared decisionmaking, although with little consensus on specific approaches. Some experts would address co‐occurring conditions related to patient safety (alcohol use, mental health symptoms, opioid side effects). Few experts referenced assessing or addressing OUD or overdose risk. In quantitative data, 36% of experts agreed LTOT is beneficial, 36% agreed most LTOT patients should be discontinued, and 57% agreed patients experience harm from tapering and from discontinuation. Discussion: Evidence is needed to build on and test these experts' recommendations to attempt tapering and add non‐opioid pain therapies for patients reporting harms of continued LTOT who may experience harms from tapering. Such evidence informs the development of clinical practice guidelines that provide comprehensive protocols to support the safety and functioning of this group of patients. [ABSTRACT FROM AUTHOR]
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  Data: <i>Copyright of Pain Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites without the copyright holder's express written permission. Additionally, content may not be used with any artificial intelligence tools or machine learning technologies. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract.</i> (Copyright applies to all Abstracts.)
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        Value: 10.1111/papr.13440
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