Tapering opioids in patients with chronic pain

An intriguing research letter found that 75% of patients on long-term opioids for chronic pain were able to decrease their opioid dose by 50% in a voluntary dose-tapering program (see opioid tapering in outpts jamaintmed2018 in dropbox,or doi:10.1001/jamainternmed.2017.8709).

Details:
 --patients treated in a community pain clinic with non-cancer chronic pain and not currently treated for substance use disorder (SUD) were provided education by their providers about the benefits of opioid reduction
--110 patients were eligible, 82 (75%) agreed to taper their dose
--of those who completed the full 4 month process: median age 52, 60% female, opioid duration 6 years
--patients were provided a self-help book and given an individualized taper: reduction of up to 5% for up to 2 dose reductions in month 1. in month 2-4, further reduction of up to 10% per week (dose decrements tailored to patient).
--monthly follow-up visits to monitor patients and dose-adjust
--follow-up surveys after 4 months

Results:
 --no problems with compliance or aberrant prescriptions, per urine tox screens and prescription drug monitoring program
--comparing baseline vs 4 month data, opioid dose decreased from 288 morphine equivalent daily dose to 150
--but, no significant difference in pain intensity (went from 5.0 to 4.5); and pretty much all other outcomes trended to being better (fatigue, anxiety, depression, sleep disturbance, pain behavior), or no change (physical function, pain interference). nothing they measured got worse
--38% did not complete the 4-month follow-up survey; only differences with those who did complete it was: more depression (p=0.05) and less marijuana use (p=0.04) in noncompleters

Commentary:
--this was a brief research letter, so not a lot of details about the study. i assume that the 110 "eligible" patients included the whole group in the pain clinic who were non-cancer, non-SUD patients. Assuming this is the case, a pretty remarkable 75% of patients were willing to try the taper
--no details on the "provider education" to help convince patients to try to decrease doses, nor the self-help book provided
--no details about the demographics of the patients. the study was done through the Stanford University dept of anesthesia, though was a "community clinic". it might have been useful also to have a breakdown of intervention effectiveness by age groups of patients (ie, were they as successful with 30 year olds as 60 yo's? were they as successful with those on opiates for only a few years as with those >10 years?), other demographics, enumeration of problems which led to opiate prescriptions, medical and psych comorbidities, socioeconomic issues, support systems, etc
--no details about early adverse effects. did patients have dysphoria, withdrawal symptoms, anxiety which were not reported at the 4 month visit? if so, how were these handled?
--nor are there further details about the actual timing and % of reductions actually done with individual patients at the different clinic visits, given the rather large reduction goals
--all of these issues make it difficult to figure out how to apply these results in other settings, but it is really impressive that 75% agreed to try the taper, they had completed 4 month results in 1/2 of them, and patients were able to achieve a 50% reduction in opioid dose with a trend to improvement in pain scores, fatigue, anxiety, sleep disturbance, and pain behavior.
--also, these patients were on megadoses of opiates (mean of 288 morphine equivalents), which decreased quite dramatically through this intervention. how would this apply to those on 90 or 120 morphine equivalents, or even 30-60 morphine equivalents??​

so, pretty striking study. at our health center we have had some successes decreasing opioid doses in some patients, through supportive encouragement. but probably the biggest lesson in this study is that if done in a systematic way and with tailoring to patient responses, many patients may be willing to try decreasing their opioid doses. and the size of the decreases achieved in this study without any deterioration of pain control was quite inspiring...