Avoiding Iatrogenic Harms of Forced Opioid Tapering

Avoiding Iatrogenic Harms of Forced Opioid Tapering

Overview

Because pain often produces psychological and cognitive effects – anxiety, depression, and anger among them – interdisciplinary, biopsychosocial approaches are the most promising for treating patients with persistent pain. – IOM, 2011

Outcomes

Learners completing this activity report improved abilities in:

• Opioid prescribing practices 
• Treating patients on long-term opioid therapy
• Determining when, and when not to taper specific patients
• Working with patients to reduce their doses, in a safe, effective manner

Accreditation & Designation

Release date: This activity was released 3/6/2020.

Peer reviewed: This activity was peer reviewed 2/10/2023

Termination date: The content of this activity remains eligible for CME Credit until 2/9/2026, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this Enduring Material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Determine when tapering a patient's opioid prescription may cause iatrogenic harm.
• Identify persons receiving long-term opioid therapy for whom tapering is both:
  • appropriate, and
  • necessary.
• Account for the neurobiological adaptations experienced by persons receiving long-term opioid therapy.
• Develop opioid tapering plans that include mitigation strategies addressing long-term psychological effects and threats to patient well-being, individualized to the needs of the patient.
• Provide leadership, professionally and as a member of my community, in addressing the opioid crisis.
  
• Communicate the goals and methods of an opioid tapering plan in a manner more likely to engender patient adherence.

Desirable Physician Attributes

• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Provide Patient-centered Care [IOM] Identify, respect, and care about patients’ differences, values, preferences and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health
• Professionalism [ACGME/ABMS] As manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

References

• CDC Guideline for Prescribing Opiates for Chronic Pain, March 18, 2016.
• Jones, C. M., Einstein, E. B., & Compton, W. M. (2018). Changes in Synthetic Opioid Involvement in Drug Overdose Deaths in the United States, 2010-2016. JAMA, 319(17), 1819-1821.
• IOM (Institute of Medicine). 2011. Patients charting the course: Citizen engagement and the learning health system: Workshop summary. Washington, DC: The National Academies Press
• Fenton, J. J., Agnoli, A. L., Xing, G., Hang, L., Altan, A. E., Tancredi, D. J., ... & Magnan, E. (2019). Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017. JAMA Network Open, 2(11), e1916271-e1916271.
• Bootzin, R. R., & Bailey, E. T. (2005). Understanding placebo, nocebo, and iatrogenic treatment effects. Journal of Clinical Psychology, 61(7), 871-880.
• Villemure, C., & Bushnell, C. M. (2002). Cognitive modulation of pain: how do attention and emotion influence pain processing?. Pain, 95(3), 195-199.
• IOM (Institute of Medicine). 2014. Partnering with patients to drive shared decisions, better value, and care improvement: Workshop proceedings. Washington, DC: The National Academies Press.
• Fenton, J. J., Agnoli, A. L., Xing, G., Hang, L., Altan, A. E., Tancredi, D. J., ... & Magnan, E. (2019). Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017. JAMA Network Open, 2(11), e1916271-e1916271.
• Darnall, B. D., Ziadni, M. S., Stieg, R. L., Mackey, I. G., Kao, M. C., & Flood, P. (2018). Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Internal Medicine, 178(5), 707-708.
• Bingel, U., Wanigasekera, V., Wiech, K., Mhuircheartaigh, R. N., Lee, M. C., Ploner, M., & Tracey, I. (2011). The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Science Translational Medicine, 3(70), 70ra14-70ra14.
• Oliva, E. M., Bowe, T., Manhapra, A., Kertesz, S., Hah, J. M., Henderson, P., ... & Trafton, J. A. (2020). Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ, 368.
• Murphy, J. L., Clark, M. E., & Banou, E. (2013). Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment. The Clinical Journal of Pain, 29(2), 109-117.
• Perez, H. R., Buonora, M., Cunningham, C. O., Heo, M., & Starrels, J. L. (2020). Opioid taper is associated with subsequent termination of care: A retrospective cohort study. Journal of General Internal Medicine, 35(1), 36-42.
• Glanz, J. M., Binswanger, I. A., Shetterly, S. M., Narwaney, K. J., & Xu, S. (2019). Association between opioid dose variability and opioid overdose among adults prescribed long-term opioid therapy. JAMA Network Open, 2(4), e192613-e192613.
• Darnall, B. D., & Colloca, L. (2018). Optimizing placebo and minimizing nocebo to reduce pain, catastrophizing, and opioid use: a review of the science and an evidence-informed clinical toolkit. In International Review of Neurobiology (Vol. 139, pp. 129-157). Academic Press.
• Demidenko, M. I., Dobscha, S. K., Morasco, B. J., Meath, T. H., Ilgen, M. A., & Lovejoy, T. I. (2017). Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. General Hospital Psychiatry, 47, 29-35.
• US Department of Health and Human Services. (2019). HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. 2019.
• Darnall, B. D., Mackey, S. C., Lorig, K., Kao, M. C., Mardian, A., Stieg, R., ... & Okvat, H. (2020). Comparative effectiveness of cognitive behavioral therapy for chronic pain and chronic pain self-management within the context of voluntary patient-centered prescription opioid tapering: The EMPOWER study protocol. Pain Medicine, 21(8), 1523-1531.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Speaker] Beth Darnall discloses the following financial relationships: Consulting: Applied VR, Axial Healthcare

Neither the peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Materials were peer-reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).