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5 Articles in this Series
Introduction
Audience Q&A: My Patients Don't See a Need for a Psychologist
Debate: Radiofrequency Ablation of the Hip (and Shoulder) Joint is Effective
Debate: SCS Is Better Than PNS for Back Pain
Inside the Poster: Methylnaltrexone for Opioid-Induced Constipation
The Deprescribing of Opioids: Toward Whole-Person Pain Care

The Deprescribing of Opioids: Toward Whole-Person Pain Care

An AAPM 2020 Highlight featuring Aram Mardian, MD, and Beth Darnall, PhD

The focus of the 2020 AAPM annual meeting, held in National Harbor, MD, moved away from a sharp focus on the 2016 CDC guidelines on opioid prescribing and toward methods and experiences with deprescribing. Opioid describing, rather than discontinuation, can mean anything from transitioning a patient to a different opioid, to the use of medication-assisted treatment (MAT) for those with opioid use disorder (OUD), to tapering and, more specifically, microtapering.

As described by Aram Mardian MD, a site director at the Phoenix VA health care system for the EMPOWER trial, noted: “Rigid guidelines on pills and dose can backfire and undermine safety. Rather, we want an individualized approach that focuses on safety.” The EMPOWER trial focuses on the comparative effectiveness of behavioral treatments in patients undergoing a collaborative opioid taper; it is being led by Beth Darnall’s team at Stanford University (https://empower.stanford.edu/).

Pointing out that recommendations have changed over time, sometimes contradicting prior recommendations (ie, the FDA’s 2019 backtracking of the 2016 CDC opioid prescribing guidelines after they were largely misapplied in chronic pain management), Dr. Mardian pointed out that the latest research on long-term opioid therapy shows that dose decreases and increases can be associated with increasing risk overall. “The gaps between evidence and practice need to be closed to move forward from here,” he said, offering four potential ways for doing so.

These four concepts, described below, should be applied across the continuum of long-term opioid therapy, from those patients who may have developed physical dependence to those who may have developed OUD, as well as those patients in between. This latter “in-between” or “gray” area is currently being explored in the pain community as “complex persistent dependence.”

Long-Term Opioid Therapy Patients are Complex and Vulnerable

First, advised Dr. Mardian, remember that neurobiological changes occur when patients take opioids; the degree of these changes can help to individualize care. Because the brain changes when on long-term opioid therapy, patient populations are both complex and vulnerable, he noted. As an example, a patient on a particular non-opioid medication that causes unwanted side effects may be able to simply stop taking that medication—this is not the case with opioids. In most cases of opioid prescribing, the risks often outweigh the benefits and since there is no clear evidence on how to reduce or deprescribe yet, he said, “perhaps the best way to reduce population exposure is to reduce the number of new starts."

iStockPhotoA whole-person approach enables the patient to understand the purpose of the multifaceted treatment plan and to take ownership of it, feeling a sense of accomplishment with each small dose reduction they achieve.

Whole-Person Pain Care Can Make All the Difference

Second, the pain community needs to undergo a paradigm shift on how it views and treats pain, from biomedical structural models to whole-person pain care. Explained Dr. Mardian, in a structural model, a pain generator is identified and then destroyed/numbed/burned or removed. But with chronic pain, this approach may actually increase harm as well as cost. “So, where should the therapeutic focus be—with the degenerated disk and the pill, or with the person and their environment?” he questioned. 

Case Example

By focusing on the latter, clinicians can focus on treating the person and not the pain specifically. Offering a hypothetical example, Dr. Mardian presented a patient case in which an individual presenting with low back pain was offered three epidural steroid injections and a forced opioid taper. The patient returned to the clinic for follow-up complaining of worse pain, sleep disturbance, and a request for an early opioid prescription refill. Eventually, the patient was discharged from the clinic for noncompliance. 

Now, take this same patient and change the initial clinical assessment to focus on his social, emotional, and physical goals. The pain care team determines that he has a BMI of 32, is physically deconditioned, is depressed, and has felt socially isolated since retiring. He is also anxious about opioid dose changes. The team focuses on educating the patient about the neurobiology of opioids, sets up regular drug monitoring screens, prescribes an exercise plan, and starts an opioid dose reduction of just 2.5%. The outcome this time: the patient returns to clinic to share that he has taken up walking, his pain level is about the same, he is seeing a psychologist for depression and anxiety, and he is ready to try another small opioid dose reduction. 

By microtapering, the opioid-pain response difference is almost indistinguishable for the patient, explained Dr. Mardian. In addition, this type of whole-person approach enables the patient to understand the purpose of the multifaceted treatment plan and to take ownership of it, feeling a sense of accomplishment with each small dose reduction they achieve. 

Specifically, Dr. Mardian suggests microtapering as follows:

  • for short acting opioids: reduce by 1⁄2 pill/day every 1 to 2 months 
  • for long acting opioids: reduce by 1 of the lowest strength pill/day every 1 to 2 months 

Individualize Care and Use the Power of Pause

As a third concept toward shifting pain care, Dr. Mardian emphasized the importance of individualizing deprescribing. Approaches “need to remain flexible and change course based on the clinical needs of patient,” he said. “Identify their unique social, psychological, and physical barriers and work on cycle of pain disability while building social-emotional and psychological support.” Factors to address may include, sleep, obesity, mental health, OUD, comorbidities, and isolation, for instance. Responses may involve the EMPOWER approach (ie, moving a patient from a pre-contemplative state around opioid deprescribing to a ready-to-act state), MAT, team-based support, and more. 

Dr. Mardian’s fourth component for moving pain management forward is the power of the pause. “If there is no imminent risk of harm to the patient and there is therapeutic uncertainty, build in the power of pause,” he said. Essentially, this involves allowing for additional time between abrupt dose changes, again, allowing the patient time to buy into the treatment plan. Overall, said Dr. Mardian, “guidelines should never be a one-size-fits-all recipe but a distillation of the best level evidence used at per-patient care level.” 

See Dr. Mardian's and Dr. Darnall's response to an audience question about including psychologists in pain care teams.

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