LTOT modification to manage ineffective or questionably effective LTOT.
LTOT can be modified in 3 ways to manage ineffective or questionably effective LTOT:
  1. Switching to long-acting opioids like buprenorphine without short acting “as needed” opioids to manage maladaptive physiological dependence.
  2. Retraining the body to function adequately with lower opioid doses (i.e., opioid tapering).
  3. Complete opioid cessation to manage excessive risk with collaboration on a treatment plan that includes engagement in non-opioid chronic pain treatment options, management of comorbidities and other supportive care.
The speed of LTOT modification is determined by the severity and immediacy of the risk determined through individual clinical evaluation.
Switching to long-acting opioids like buprenorphine: In LTOT ineffectiveness, it is accepted that the maladaptive LTOT dependence is usually a major source of pain and disability. The clinical logic of switching to a long-acting opioid alone is to provide a steady state of opioid instead of frequently fluctuating opioid levels so that the body has a better chance of maintaining physiological and functional stability; an approach that is similar to the treatment strategy for dysfunctional opioid dependence in OUD.52,73 An essential component to this strategy’s success is the patient and provider accepting that the goal of treatment with long-acting opioids as improving functional stability (able to do more, sleep better, maintain better mood etc.) and not pain reduction. It is critical for the patients or the providers not to use pain levels to measure the response of the long-acting opioid switch as the pain might or might not improve. The patients should be encouraged to collaborate with providers to learn to manage frequent pain exacerbations related to implicit and explicit expectancy effects that can be addressed using evidence-based non-pharmacological coping skills (e.g., relaxation techniques). It is critical to avoid use of any medications or other interventions that provide short term pain reduction to treat these “breakthrough” pains, a term that came from the hospice care literature that has limited utility in conceptualization of the chronic pain experience. Patients and providers should collaboratively decide the functional goals of treatment as detailed in the LTOT initiation section. The patient must be empowered, with guidance from providers, to take advantage of the initial functional stability they may experience on opioids and work on improving function with varying pain levels. It is often difficult for many patients and even providers to accept the concept that a pain medication is causing pain, and the appropriate treatment is not additional medications. The idea of functional recovery with the current level of pain and without further reduction can also be challenging to many patients. So, patience, compassion, and willingness to initiate and repeatedly engage in collaborative discussions by the treating provider is critical for continued patient engagement and success in treatment. The long-term goal is to gain and sustain best possible level of function on long-acting opioid regimen for a few years and retrain the body to function with lower opioid doses that finally leads to a functional life without opioids (a more detailed description provided below). Acceptance that the recovery journey belongs to the patient and providers can only help and provide guidance can facilitate collaboration and build empathy.
Buprenorphine formulations are the preferred long-acting opioids in the management of ineffective LTOT because of its favorable safety profile.52,74-76 Use of other long-acting opioids in these scenarios is controversial and yet fairly common, often because of inertia – making a change takes time and experience that many providers lack. We include the discussion below with the blanket recognition that more research is needed in terms of long-term outcomes with these strategies. Methadone is another long-acting opioid that has been used in treatment of maladaptive opioid dependence and chronic pain, but concerns about excessive risk especially in the older age groups limits its use.77,78 If buprenorphine is not a viable choice, other long-acting formulations of short acting opioids like sustained release morphine or oxycodone may also be used as less optimal treatment options. It is critical to explain to the patients who are accustomed to these medications as pain medications that they are used as treatment of maladaptive LTOT dependence and deviating from the prescription instructions is extremely dangerous and can render the treatment ineffective. In general, we recommend avoiding fentanyl transdermal patches as they have several safety and pharmacokinetic concerns. More detailed discussion of long-acting opioids is provided in Appendix 2.
Retraining for a functional life with lower opioid doses: Although planned slow opioid dose reduction is commonly referred to as opioid tapering, a pharmaco-centric terminology and concept, the process is ideally about the person engaging in functional retraining to maintain an adequately functional life with lower opioid doses. It is important to recognize that achievement of lower opioid dose levels or opioid cessation that simultaneously creates functional and medical instability cannot be considered an effective opioid tapering intervention. We prefer the person-centric approach of functional retraining with lower opioid dose. This functional approach might involve a shift from the medication centric opioid tapering protocols with specific percentage of doses to be decreased at pre-defined time intervals to a more comprehensive behavioral intervention that allows the patient to maintain function while reducing opioid doses at an accommodative pace. In our clinical experience, this requires a high level of motivation and effort from the patient and flexibility from the provider. Many patients find this a difficult task because of the protracted withdrawal symptoms and the often lengthy durations (months to years) of the process. So, empathetic communication and enhanced patient motivation are critical to the success of this strategy. It is important for both patients and providers to recognize that opioid deprescribing can increase the opioid related risks like overdose and suicides. 27-39 Thus, patients should be closely monitored and supported during opioid deprescribing. We caution against substituting opioids with polypharmacy using central nervous system agents like anti-depressants, gabapentinoids, tricyclic anti-depressants, muscle relaxants, etc. as it can increase opioid related risks considerably.72
Complete quick LTOT cessation: In cases where LTOT must be discontinued quickly as with opioid prescription diversion or high-impact adverse effects, close medical management of adverse consequences and continued engagement for risk mitigation may be essential. Patients should be advised and supported to engage in a treatment plan for functional recovery without opioids. Non-fatal overdose events, especially with no misuse, creates a challenging situation with patients because opioid discontinuation can create more disability and medical instability and increase the risk for further overdose and suicide. Therefore, the decision to discontinue LTOT should be carefully weighed against the option of treatment of maladaptive opioid dependence with long-acting opioids incorporating inputs from the patient and other individuals involved in the patient’s care (e.g., family members). Providers must engage patients in alternative management strategies for management of chronic pain and comorbidities, and patient should receive general supportive care. These patients should be monitored closely as opioid deprescribing is associated with elevated risk. 27-39