LTOT Initiation
Since physiological opioid dependence is unavoidable with LTOT, the decisions regarding LTOT initiation should be based on a shared determination by the provider and the patient on whether an adaptive LTOT dependence or maladaptive dependence with OICP is more likely, at least initially. In simple terms, functional improvement, the goal of LTOT, can be defined as the objective achievement of a functional status comparable to a similar person of same age and gender without chronic pain, or a substantial improvement in disability. The objective functional improvement goal of LTOT should be collaboratively determined by the provider and patient before LTOT initiation to make easy determination of its effectiveness or lack thereof during follow up. In addition to thorough discussion of the risks of LTOT, a frank discussion with the patient should also address the different aspects of LTOT and OICP listed in Box 4. The patient should be closely monitored for progress toward functional improvement goals once LTOT is initiated. LTOT should be withdrawn at 3 months if no meaningful functional improvement is achieved regardless of pain relief. Functional improvement with opioids indicates that a significant part of the disability is not driven by biomechanical or physical reasons like arthritis or disc disease as opioids are unable to repair damage from physical disease. So, patients should work to maximize function on the established LTOT dose. LTOT should not be approached as a lifelong treatment because of the risk of adverse outcomes and high chance of developing maladaptive opioid dependence that is difficult to reverse. After achievement and stabilization of functional improvement goals, the patient and the provider must work on training the individual to function at the same level with lower and lower doses of LTOT. The eventual goal should be to have an adequately functional life without opioid dependence. We recommend that LTOT maintenance should be used for the shortest duration necessary to achieve sustained functional improvement. Even with adaptive opioid dependence, we further recommend against LTOT maintenance beyond 1 or 2 years.
The functional goals of LTOT can be challenging to establish and monitor as routine objective measures of function like Oswestry disability index, PEG score or short form-12 can be tricky to use among LTOT patients as they may fail to capture the nuance of functional improvement. In clinical practice, we have found that a more narrative descriptions of global function are more meaningful- Is the patient able to do more, sleep better, participate in family roles more, work easier, have better relationships, be less angry, have better mood and less anxiety, etc.
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