Conclusions:
LTOT is often the only available choice for patients with chronic pain who are unable to recover function despite various interventions and will likely remain so for the foreseeable future. Re-conceptualization of opioids as a complex relief medication and LTOT as therapeutic induction of functionally adaptive opioid dependence enables us to consider LTOT dependence as a tool to facilitate functional rehabilitation with provider and patient collaboration around the decision to initiate LTOT. However, if LTOT is initiated, it should be done so with the clear plan for ongoing reassessment and duration of therapy no longer than ~ 2 years. Having a planned maximal duration of therapy can help avoid the development of OICP, but OICP may manifest before that period. The diagnosis of OICP can address the stigma of addiction associated with the use of the term “dependence” and facilitate engagement with an individual patient with chronic pain who is not doing well on LTOT. OICP is a difficult iatrogenic problem and any temptation to blame the patient should be avoided. LTOT reevaluation based on the concept of adaptive versus maladaptive opioid dependence can also demystify the opaque process of LTOT revaluation. We hope these concepts and principles offered her would lead to more fruitful collaborations between patients, providers, researchers, payors, and policy makers. There is a need for further research on the conceptualization of effective LTOT as therapeutic induction of physiological opioid dependence.
Acknowledgement: The concepts in this manuscript was initially developed by Ajay Manhapra and refined further through discussion between the authors. Ajay Manhapra prepared the first draft of the manuscript and all authors revised subsequent versions of the manuscript.
Conflict of Interest statements: The authors have no conflict of interest to report.
Funding information: Support for Dr. MacLean is provided by VA Clinical Science Research and Development Career Development Award (1IK2CX002286). No other funding was involved in the preparation of this manuscript.
Data availability statement: No primary data was used.
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