Box 4: Elements of long-term opioid therapy (LTOT) to be
discussed with patient before LTOT initiation
- LTOT should not be approached as a simple pain reduction
strategy but as induction of therapeutic opioid dependence that can
have beneficial as well as adverse outcomes.
- The goal of LTOT is functional improvement irrespective of
whether sustained pain relief is achieved. LTOT can improve function
without pain reduction and pain reduction without functional
improvement is not a justifiable reason to continue LTOT.
- Improvement of function with LTOT indicates that the functional
limitations were not purely biomechanical or physical limitations as
opioids do not cure, or correct physical diseases. There would be
further room for functional improvement with the level of pain and
physical diseases the patient has.
- Physiological LTOT dependence can transform to maladaptive
opioid dependence with paradoxical opioid induced chronic pain
syndrome (OICP) that leads to LTOT ineffectiveness. The psychiatric
and medical symptoms may also worsen along with worsening of pain as a
part of OICP.
- In OICP from LTOT, while the overall function and pain worsens,
each opioid dose can continue to provide relief creating a false
impression that LTOT is still “working.”
- OICP can present as increased opioid need experienced by the
patient. However, opioid dose escalation will not likely lead to
sustained improvement in function and may cause worsening of OICP.
- OICP is often clinically indistinguishable from worsening of
other chronic pain conditions like arthritis and psychiatric or
medical diseases.
- Deprescribing ineffective LTOT is often a difficult task and may
lead to worsening pain and medical instability.
- Increased pain and disability following opioid dose reduction
cannot be interpreted as proof that LTOT was working, that physical
chronic pain conditions have worsened or that there is a medical need
to continue LTOT.
- The worsening of pain and disability following LTOT cessation or
dose reduction can mimic clinical worsening of chronic pain conditions
like arthritis and should not be investigated or treated as such. Such
worsening of function and pain can persist for years after LTOT dose
reduction or cessation.
—————–End
Box—————————-