LTOT modification to manage ineffective or questionably
effective LTOT.
LTOT can be modified in 3 ways to manage ineffective or questionably
effective LTOT:
- Switching to long-acting opioids like buprenorphine without short
acting “as needed” opioids to manage maladaptive physiological
dependence.
- Retraining the body to function adequately with lower opioid doses
(i.e., opioid tapering).
- Complete opioid cessation to manage excessive risk with collaboration
on a treatment plan that includes engagement in non-opioid chronic
pain treatment options, management of comorbidities and other
supportive care.
The speed of LTOT modification is determined by the severity and
immediacy of the risk determined through individual clinical evaluation.
Switching to long-acting opioids like buprenorphine: In
LTOT ineffectiveness, it is accepted that the maladaptive LTOT
dependence is usually a major source of pain and disability. The
clinical logic of switching to a long-acting opioid alone is to provide
a steady state of opioid instead of frequently fluctuating opioid levels
so that the body has a better chance of maintaining physiological and
functional stability; an approach that is similar to the treatment
strategy for dysfunctional opioid dependence in
OUD.52,73 An essential component to this strategy’s
success is the patient and provider accepting that the goal of treatment
with long-acting opioids as improving functional stability (able to do
more, sleep better, maintain better mood etc.) and not pain reduction.
It is critical for the patients or the providers not to use pain levels
to measure the response of the long-acting opioid switch as the pain
might or might not improve. The patients should be encouraged to
collaborate with providers to learn to manage frequent pain
exacerbations related to implicit and explicit expectancy effects that
can be addressed using evidence-based non-pharmacological coping skills
(e.g., relaxation techniques). It is critical to avoid use of any
medications or other interventions that provide short term pain
reduction to treat these “breakthrough” pains, a term that came from
the hospice care literature that has limited utility in
conceptualization of the chronic pain experience. Patients and providers
should collaboratively decide the functional goals of treatment as
detailed in the LTOT initiation section. The patient must be empowered,
with guidance from providers, to take advantage of the initial
functional stability they may experience on opioids and work on
improving function with varying pain levels. It is often difficult for
many patients and even providers to accept the concept that a pain
medication is causing pain, and the appropriate treatment is not
additional medications. The idea of functional recovery with the current
level of pain and without further reduction can also be challenging to
many patients. So, patience, compassion, and willingness to initiate and
repeatedly engage in collaborative discussions by the treating provider
is critical for continued patient engagement and success in treatment.
The long-term goal is to gain and sustain best possible level of
function on long-acting opioid regimen for a few years and retrain the
body to function with lower opioid doses that finally leads to a
functional life without opioids (a more detailed description provided
below). Acceptance that the recovery journey belongs to the patient and
providers can only help and provide guidance can facilitate
collaboration and build empathy.
Buprenorphine formulations are the preferred long-acting opioids in the
management of ineffective LTOT because of its favorable safety
profile.52,74-76 Use of other long-acting opioids in
these scenarios is controversial and yet fairly common, often because of
inertia – making a change takes time and experience that many providers
lack. We include the discussion below with the blanket recognition that
more research is needed in terms of long-term outcomes with these
strategies. Methadone is another long-acting opioid that has been used
in treatment of maladaptive opioid dependence and chronic pain, but
concerns about excessive risk especially in the older age groups limits
its use.77,78 If buprenorphine is not a viable choice,
other long-acting formulations of short acting opioids like sustained
release morphine or oxycodone may also be used as less optimal treatment
options. It is critical to explain to the patients who are accustomed to
these medications as pain medications that they are used as treatment of
maladaptive LTOT dependence and deviating from the prescription
instructions is extremely dangerous and can render the treatment
ineffective. In general, we recommend avoiding fentanyl transdermal
patches as they have several safety and pharmacokinetic concerns. More
detailed discussion of long-acting opioids is provided in Appendix 2.
Retraining for a functional life with lower opioid
doses: Although planned slow opioid dose reduction is commonly
referred to as opioid tapering, a pharmaco-centric terminology and
concept, the process is ideally about the person engaging in functional
retraining to maintain an adequately functional life with lower opioid
doses. It is important to recognize that achievement of lower opioid
dose levels or opioid cessation that simultaneously creates functional
and medical instability cannot be considered an effective opioid
tapering intervention. We prefer the person-centric approach of
functional retraining with lower opioid dose. This functional approach
might involve a shift from the medication centric opioid tapering
protocols with specific percentage of doses to be decreased at
pre-defined time intervals to a more comprehensive behavioral
intervention that allows the patient to maintain function while reducing
opioid doses at an accommodative pace. In our clinical experience, this
requires a high level of motivation and effort from the patient and
flexibility from the provider. Many patients find this a difficult task
because of the protracted withdrawal symptoms and the often lengthy
durations (months to years) of the process. So, empathetic communication
and enhanced patient motivation are critical to the success of this
strategy. It is important for both patients and providers to recognize
that opioid deprescribing can increase the opioid related risks like
overdose and suicides. 27-39 Thus, patients should be
closely monitored and supported during opioid deprescribing. We caution
against substituting opioids with polypharmacy using central nervous
system agents like anti-depressants, gabapentinoids, tricyclic
anti-depressants, muscle relaxants, etc. as it can increase opioid
related risks considerably.72
Complete quick LTOT cessation: In cases where LTOT must
be discontinued quickly as with opioid prescription diversion or
high-impact adverse effects, close medical management of adverse
consequences and continued engagement for risk mitigation may be
essential. Patients should be advised and supported to engage in a
treatment plan for functional recovery without opioids. Non-fatal
overdose events, especially with no misuse, creates a challenging
situation with patients because opioid discontinuation can create more
disability and medical instability and increase the risk for further
overdose and suicide. Therefore, the decision to discontinue LTOT should
be carefully weighed against the option of treatment of maladaptive
opioid dependence with long-acting opioids incorporating inputs from the
patient and other individuals involved in the patient’s care (e.g.,
family members). Providers must engage patients in alternative
management strategies for management of chronic pain and comorbidities,
and patient should receive general supportive care. These patients
should be monitored closely as opioid deprescribing is associated with
elevated risk. 27-39