Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for Buprenorphine
Authors: Roger Chou, Jane Ballantyne, Anna Lembke
Journal: Annals of Internal Medicine (2019)

Ideas and Opinions17 September 2019Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for BuprenorphineCorrection(s) for this article:CorrectionsNov 2019Correction: Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for BuprenorphineFREERoger Chou, MD, Jane Ballantyne, MD, and Anna Lembke, MDRoger Chou, MDOregon Health & Science University, Portland, Oregon (R.C.), Jane Ballantyne, MDUniversity of Washington School of Medicine, Seattle, Washington (J.B.), and Anna Lembke, MDStanford University School of Medicine, Stanford, California (A.L.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-1488 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The expanded use of opioids for chronic pain has created a population of patients prescribed long-term opioid therapy lasting years or decades. Doses are often above the thresholds suggested in the 2016 Centers for Disease Control and Prevention (CDC) guideline (morphine-equivalent dose >50 or >90 mg/d) (1). Long-term opioid therapy is associated with adverse effects, morbidity, and overdose death; some risks are dose-dependent (2). At the same time, evidence indicates that long-term opioid therapy confers little benefit versus nonopioid therapy, particularly for function (3). Opioid use disorder (OUD) occurs in a subset of patients, and quality of life may be ...References1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315:1624-45. [PMID: 26977696] doi:10.1001/jama.2016.1464 CrossrefMedlineGoogle Scholar2. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162:276-86. [PMID: 25581257]. doi:10.7326/M14-2559 LinkGoogle Scholar3. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta-analysis. JAMA. 2018;320:2448-60. [PMID: 30561481] doi:10.1001/jama.2018.18472 CrossrefMedlineGoogle Scholar4. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156:569-76. [PMID: 25785523] doi:10.1097/01.j.pain.0000460357.01998.f1 CrossrefMedlineGoogle Scholar5. Dowell D, Haegerich TM. Changing the conversation about opioid tapering. Ann Intern Med. 2017;167:208-9. [PMID: 28715842]. doi:10.7326/M17-1402 LinkGoogle Scholar6. Darnall BD, Ziadni MS, Stieg RL, et al. Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Intern Med. 2018;178:707-8. [PMID: 29459978] doi:10.1001/jamainternmed.2017.8709 CrossrefMedlineGoogle Scholar7. Frank JW, Lovejoy TI, Becker WC, et al. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Ann Intern Med. 2017;167:181-91. [PMID: 28715848]. doi:10.7326/M17-0598 LinkGoogle Scholar8. Oregon Pain Guidance Clinical Advisory Group Tapering Workgroup. Tapering—Guidance & Tools: Clinical Update Dec. 2018. Accessed at www.oregonpainguidance.org/guideline/tapering on 7 July 2019. Google Scholar9. Stanford Center for Continuing Medical Education. How to Taper Patients Off of Chronic Opioid Therapy. Accessed at https://stanford.cloud-cme.com/default.aspx?P=0&EID=20909 on 7 July 2019. Google Scholar10. White JM. Pleasure into pain: the consequences of long-term opioid use. Addict Behav. 2004;29:1311-24. [PMID: 15345267] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Oregon Health & Science University, Portland, Oregon (R.C.)University of Washington School of Medicine, Seattle, Washington (J.B.)Stanford University School of Medicine, Stanford, California (A.L.)Acknowledgment: The authors thank the Oregon Pain Guidance Working Group (Jane Ballantyne, Roger Chou, Paul Coelho, Ruben Halperin, Andrew Kolodny, Anna Lembke, Jim Shames, Mark Stephens, and David Tauben) for discussions about tapering and for reviewing a draft of this article.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1488.Corresponding Author: Roger Chou, MD, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: BICC, Portland, OR 97239; e-mail, [email protected]edu.Current Author Addresses: Dr. Chou: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: BICC, Portland, OR 97239.Dr. Ballantyne: Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Mail Code: BB 1421, Seattle, WA 98195.Dr. Lembke: Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305.Author Contributions: Conception and design: R. Chou, A. Lembke.Analysis and interpretation of the data: R. Chou.Drafting of the article: R. Chou, J. Ballantyne, A. Lembke.Critical revision of the article for important intellectual content: R. Chou, J. Ballantyne, A. Lembke.Final approval of the article: R. Chou, J. Ballantyne, A. Lembke.Administrative, technical, or logistic support: R. Chou.Collection and assembly of data: R. Chou.This article was published at Annals.org on 27 August 2019. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCorrection: Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for BuprenorphineBuprenorphine for Long-Term Chronic Pain Management: Still Looking for the Evidence Michael E. Schatman , Hannah Shapiro , and David J. DiBenedetto Buprenorphine for Long-Term Chronic Pain Management: Still Looking for the Evidence Roger Chou , Jane Ballantyne , and Anna Lembke Metrics Cited byDeveloping an interprofessional team to support patients prescribed long-term high-dose opioid therapyOpioid deprescribing in patients with chronic noncancer pain: a systematic review of international guidelinesOpioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare settingVariation in Clinical Characteristics and Longitudinal Outcomes in Individuals with Opioid Use Disorder Diagnosis CodesTop Ten Tips Palliative Care Clinicians Should Know About BuprenorphineEvaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptionsBuprenorphine/naloxone versus methadone opioid rotation in patients with prescription opioid use disorder and chronic pain: study protocol for a randomized controlled trialQualitative exploration of the psychological dimensions of telehealth shared medical appointments (SMAs) for buprenorphine prescribingCDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022Self-reported Use of Prescribed Buprenorphine Among US Adults With Nonmedical Use of Prescription Opioids Motivated by PainUnderstanding the Risks of Long-Term Opioid Therapy for Chronic PainDelphi study to explore a new diagnosis for "ineffective" long-term opioid therapy for chronic painOpioids: Taper or Not?Arguments for and Against a New Diagnostic Entity for Patients With Chronic Pain on Long-Term Opioid Therapy for Whom Harms Outweigh BenefitsAssociation of Opioid Dose Reduction With Opioid Overdose and Opioid Use Disorder Among Patients Receiving High-Dose, Long-term Opioid Therapy in North CarolinaOpioid dependence disorder and comorbid chronic pain: comparison of groups based on patient-attributed direction of the causal relationship between the two conditionsTapering Opioids for Chronic Pain: Further Evidence of Alarming Risks for Millions of PatientsOpioids for chronic pain management in patients with dialysis-dependent kidney failurePatient outcomes after opioid dose reduction among patients with chronic opioid therapyEvaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic PainMood Disturbances Associated with Long-Term Opioid Therapy #418Treatment of opioid use disorder in primary careState Medical Board Policy and Opioid Prescribing: A Controlled Interrupted Time SeriesFive Things to Know When a Psychiatric Patient Is Prescribed Opioids for PainDepression and Buprenorphine Treatment in Patients with Non-cancer Pain and Prescription Opioid Dependence without Comorbid Substance Use DisordersSwitching From High-Dose, Long-Term Opioids to Buprenorphine: A Case SeriesWilliam C. Becker, MD, Joseph W. Frank, MD, MPH, and Ellen L. Edens, MD, MPEThe Daunting Challenge of Helping Millions of Patients Taper or Discontinue Opioid TherapyBuprenorphine for Long-Term Chronic Pain Management: Still Looking for the EvidenceMichael E. Schatman, PhD, Hannah Shapiro, and David J. DiBenedetto, MDPatient-Centered Reduction or Discontinuation of Long-term Opioid AnalgesicsCorrection: Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for Buprenorphine 17 September 2019Volume 171, Issue 6Page: 427-429KeywordsDiagnostic and Statistical Manual of Mental Disorders fifth editionDisclosureDrug administrationDrugsMorbidityOpioid addictionOpioid use disorderOpioidsQuality of lifeTherapeutic drug monitoring ePublished: 27 August 2019 Issue Published: 17 September 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...