Box 4: Elements of long-term opioid therapy (LTOT) to be discussed with patient before LTOT initiation
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.”
  6. 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.
  7. OICP is often clinically indistinguishable from worsening of other chronic pain conditions like arthritis and psychiatric or medical diseases.
  8. Deprescribing ineffective LTOT is often a difficult task and may lead to worsening pain and medical instability.
  9. 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.
  10. 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.
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