LTOT Initiation
Since physiological opioid dependence is unavoidable with LTOT, the
decisions regarding LTOT initiation should be based on a shared
determination by the provider and the patient on whether an adaptive
LTOT dependence or maladaptive dependence with OICP is more likely, at
least initially. In simple terms, functional improvement, the goal of
LTOT, can be defined as the objective achievement of a functional status
comparable to a similar person of same age and gender without chronic
pain, or a substantial improvement in disability. The objective
functional improvement goal of LTOT should be collaboratively determined
by the provider and patient before LTOT initiation to make easy
determination of its effectiveness or lack thereof during follow up. In
addition to thorough discussion of the risks of LTOT, a frank discussion
with the patient should also address the different aspects of LTOT and
OICP listed in Box 4. The patient should be closely monitored for
progress toward functional improvement goals once LTOT is initiated.
LTOT should be withdrawn at 3 months if no meaningful functional
improvement is achieved regardless of pain relief. Functional
improvement with opioids indicates that a significant part of the
disability is not driven by biomechanical or physical reasons like
arthritis or disc disease as opioids are unable to repair damage from
physical disease. So, patients should work to maximize function on the
established LTOT dose. LTOT should not be approached as a lifelong
treatment because of the risk of adverse outcomes and high chance of
developing maladaptive opioid dependence that is difficult to reverse.
After achievement and stabilization of functional improvement goals, the
patient and the provider must work on training the individual to
function at the same level with lower and lower doses of LTOT. The
eventual goal should be to have an adequately functional life without
opioid dependence. We recommend that LTOT maintenance should be used for
the shortest duration necessary to achieve sustained functional
improvement. Even with adaptive opioid dependence, we further recommend
against LTOT maintenance beyond 1 or 2 years.
The functional goals of LTOT can be challenging to establish and monitor
as routine objective measures of function like Oswestry disability
index, PEG score or short form-12 can be tricky to use among LTOT
patients as they may fail to capture the nuance of functional
improvement. In clinical practice, we have found that a more narrative
descriptions of global function are more meaningful- Is the patient able
to do more, sleep better, participate in family roles more, work easier,
have better relationships, be less angry, have better mood and less
anxiety, etc.
————————Start
Box———————