Reevaluation of LTOT effectiveness among patients dependent on
LTOT
The first step in LTOT reevaluation for those who have been on LTOT for
considerable time is to evaluate if the patient has a diagnosis of DSM-5
OUD or ICD-10 Opioid Dependence. The patient should be directed to
proper care if OUD is diagnosed. If there is no OUD, further decisions
regarding LTOT effectiveness must be made by weighing the LTOT benefit
of functional improvement against the accumulated harms and future risk.
Estimating LTOT benefit: When reevaluating the benefit
of LTOT, it is critical for patients and providers to assess whether
LTOT dependence is associated with ongoing functional improvement over
the entire duration of LTOT, and not whether each dose improves pain or
disability for a few hours daily. Such ascertainment of benefits can be
challenging among patients on LTOT for several years or decades (i.e.,
”legacy” LTOT patients) being reevaluated by a new provider because
details regarding functional status and functional improvement goals set
before LTOT initiation are commonly unavailable or has changed over the
years. To remedy such challenges, we suggest that sustained LTOT benefit
can be clinically evaluated by addressing two simple sequential clinical
questions;
1) is the individual function similar to that another healthy person of
similar age and gender?, and,
2) is the functional level or disability substantially improved compared
to the time before LTOT initiation?
LTOT can be considered beneficial if the answer to either of these
questions is “yes” and not beneficial if the answer is “no” to both
questions. The definition of the degree of disability improvement that
can be considered as beneficial must be determined through a
collaborative discussion between patients and providers and needs to be
updated over time. Such functional evaluations should also consider how
the functional ability may change with ageing. As stated in the LTOT
initiation section, a global narrative functional assessment may be more
meaningful than self-reported measures, especially if the patient has
difficulty with numeracy.
A careful longitudinal history of the evolution of pain, function, and
overall clinical status before and after LTOT initiation is an essential
component of LTOT reevaluation. Without the longitudinal history or
long-term perspective, clinicians and patients often fall into the trap
of misinterpreting transient pain relief and functional improvement
following each dose as evidence of LTOT effectiveness or disease
progression, for Example: “I get relief and can do more for a few hours
after I take my pain medication. Then, the pain becomes severe, and I
must lay in bed the rest of the time. My pain medications are working,
but my arthritis is getting worse as I grow older.” As described in a
prior section, the above complex clinical phenomenology associated with
LTOT can be explained by OICP driven by allostatic opponent effect, an
adverse effect of LTOT rarely acknowledged or discussed in the pain
literature. Similarly, there is limited recognition of protracted
withdrawal syndrome following LTOT cessation or dose reduction
(described in prior section) in the pain literature or clinical pain
practice. Any effect of opioid dose reduction or cessation beyond the
7-10 days of acute withdrawals, a commonly recognized self-limiting
clinical entity associated with worsening pain, are deemed by clinicians
and patients as clinical phenomenology unrelated to LTOT dependence.
Hence, the worsening of pain and functioning following LTOT dose
reduction or cessation followed by limited restoration of function after
the reinstatement of prior LTOT dose should not be used to justify
continuation of LTOT (Example: “My pain became unbearable when I
stopped the opioids for a few months. I could not even get out of the
bed. I did much better when the doctor put me back on my pain
medications. I can do things now for a few hours after each dose of pain
medications. I got real pain due to arthritis getting bad and my
pain medication are helping with that.”).
Accumulated harms of LTOT: A risk estimation evaluation
includes accounting of the high-impact harms like non-fatal overdose,
respiratory failure and severe bowel obstruction that have occurred
already (see Box 5 for more complete list). Surprisingly, most patients
continue to be on opioids despite occurrence of severe harms like
overdose.24 A risk evaluation should acknowledge that
the future risk of similar harms in the future is significantly high
after the occurrence of an event like overdose.24
Estimation of future risks of LTOT: An objective
assessment of future risk of severe harms like overdose and mortality
should be made. Such estimation of risk should acknowledge that
indicators of the overall mental and physical health of the individual
like the need for psychoactive polypharmacy for chronic pain and other
symptoms (gabapentin, antidepressants, muscle relaxants, tricyclics,
psychiatric medications etc.), medical, psychiatric and substance use
disorder comorbidities, and the recent use of acute hospital based
treatments for those conditions may be more important than commonly
recognized risk indicators like higher opioid dose or benzodiazepine
co-prescription.72 Risk calculators like
Stratification Tool for Opioid Risk Mitigation (STORM) used in the
United States Veterans Health Administration facilities may provide an
automated risk estimation using electronic medical records data.72
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