Reevaluation of LTOT effectiveness among patients dependent on LTOT
The first step in LTOT reevaluation for those who have been on LTOT for considerable time is to evaluate if the patient has a diagnosis of DSM-5 OUD or ICD-10 Opioid Dependence. The patient should be directed to proper care if OUD is diagnosed. If there is no OUD, further decisions regarding LTOT effectiveness must be made by weighing the LTOT benefit of functional improvement against the accumulated harms and future risk.
Estimating LTOT benefit: When reevaluating the benefit of LTOT, it is critical for patients and providers to assess whether LTOT dependence is associated with ongoing functional improvement over the entire duration of LTOT, and not whether each dose improves pain or disability for a few hours daily. Such ascertainment of benefits can be challenging among patients on LTOT for several years or decades (i.e., ”legacy” LTOT patients) being reevaluated by a new provider because details regarding functional status and functional improvement goals set before LTOT initiation are commonly unavailable or has changed over the years. To remedy such challenges, we suggest that sustained LTOT benefit can be clinically evaluated by addressing two simple sequential clinical questions;
1) is the individual function similar to that another healthy person of similar age and gender?, and,
2) is the functional level or disability substantially improved compared to the time before LTOT initiation?
LTOT can be considered beneficial if the answer to either of these questions is “yes” and not beneficial if the answer is “no” to both questions. The definition of the degree of disability improvement that can be considered as beneficial must be determined through a collaborative discussion between patients and providers and needs to be updated over time. Such functional evaluations should also consider how the functional ability may change with ageing. As stated in the LTOT initiation section, a global narrative functional assessment may be more meaningful than self-reported measures, especially if the patient has difficulty with numeracy.
A careful longitudinal history of the evolution of pain, function, and overall clinical status before and after LTOT initiation is an essential component of LTOT reevaluation. Without the longitudinal history or long-term perspective, clinicians and patients often fall into the trap of misinterpreting transient pain relief and functional improvement following each dose as evidence of LTOT effectiveness or disease progression, for Example: “I get relief and can do more for a few hours after I take my pain medication. Then, the pain becomes severe, and I must lay in bed the rest of the time. My pain medications are working, but my arthritis is getting worse as I grow older.” As described in a prior section, the above complex clinical phenomenology associated with LTOT can be explained by OICP driven by allostatic opponent effect, an adverse effect of LTOT rarely acknowledged or discussed in the pain literature. Similarly, there is limited recognition of protracted withdrawal syndrome following LTOT cessation or dose reduction (described in prior section) in the pain literature or clinical pain practice. Any effect of opioid dose reduction or cessation beyond the 7-10 days of acute withdrawals, a commonly recognized self-limiting clinical entity associated with worsening pain, are deemed by clinicians and patients as clinical phenomenology unrelated to LTOT dependence. Hence, the worsening of pain and functioning following LTOT dose reduction or cessation followed by limited restoration of function after the reinstatement of prior LTOT dose should not be used to justify continuation of LTOT (Example: “My pain became unbearable when I stopped the opioids for a few months. I could not even get out of the bed. I did much better when the doctor put me back on my pain medications. I can do things now for a few hours after each dose of pain medications. I got real pain due to arthritis getting bad and my pain medication are helping with that.”).
Accumulated harms of LTOT: A risk estimation evaluation includes accounting of the high-impact harms like non-fatal overdose, respiratory failure and severe bowel obstruction that have occurred already (see Box 5 for more complete list). Surprisingly, most patients continue to be on opioids despite occurrence of severe harms like overdose.24 A risk evaluation should acknowledge that the future risk of similar harms in the future is significantly high after the occurrence of an event like overdose.24
Estimation of future risks of LTOT: An objective assessment of future risk of severe harms like overdose and mortality should be made. Such estimation of risk should acknowledge that indicators of the overall mental and physical health of the individual like the need for psychoactive polypharmacy for chronic pain and other symptoms (gabapentin, antidepressants, muscle relaxants, tricyclics, psychiatric medications etc.), medical, psychiatric and substance use disorder comorbidities, and the recent use of acute hospital based treatments for those conditions may be more important than commonly recognized risk indicators like higher opioid dose or benzodiazepine co-prescription.72 Risk calculators like Stratification Tool for Opioid Risk Mitigation (STORM) used in the United States Veterans Health Administration facilities may provide an automated risk estimation using electronic medical records data.72
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