Even if a chronic pain patient had been taking opioid medications exactly as prescribed, it would still be possible for the patient to experience negative cognitive and emotional responses to dose tapering that could amplify sensory pain and lead to opioid addiction.
Even if a chronic pain patient had been taking opioid medications exactly as prescribed, it would still be possible for the patient to experience negative cognitive and emotional responses to dose tapering that could amplify sensory pain and lead to opioid addiction, Beth Darnall, PhD, Clinical Associate Professor in the Division of Pain Medicine at Stanford University, explained in a pain psychology session she moderated at the American Academy of Pain Medicine (AAPM) 2014 Annual Meeting, held March 6-9, 2014, in Phoenix, AZ.
“There’s a huge focus on ‘red flag’ behaviors in patients, but if any of us are prescribed opioids, they will affect us in a predicable way,” Darnall said during the “Mind over Pill: Reducing Opioids and Optimizing Psychology” panel presentation. “You can have the most compliant patient in the world, yet you can still help them understand how opioids influence their behaviors.”
According to Mark Sullivan, MD, PhD, of the Department of Psychiatry and Behavioral Studies at the University of Washington, the endogenous opioid system is “core to a lot more functions than just analgesia,” as it plays a role in addiction to stimulants, alcohol, nicotine, and cannabis; mental health disorders such as depression, stress, and borderline personality disorder; endocrine dysfunction in terms of fertility, sexuality, and maternal-infant bonding; and gastrointestinal (GI), renal, and hepatic functions. As a result, Sullivan said “opioid use and taper affect many domains of experience and behavior.”
Although the vast majority of opioid therapy is short-term, Sullivan noted the duration and dosage of chronic opioid treatment is increasing, and after 90 days of continuous use, patients often remain on opioids for years “with no natural endpoint.”
In its attempt to determine what can be done to encourage the discontinuation of chronic opioid therapy, the Prescription Opiate Abuse Treatment Study (POATS) found that <10% of patients addicted to prescription opioids were able to successfully abstain from the painkillers after receiving buprenorphine for 3 months followed by an opioid taper over a 1-month period and combined with intensive psychosocial support. However, Sullivan indicated the POATS study left out non-addicted patients, so he recently launched a Prescription Opioid Taper Study (POTS) to “test the idea that early taper support and skills training can help those people stay off opioids, as compared to usual care.”
Even though POTS only recently began enrolling study subjects, Sullivan said he has already gathered that “opioid cessation is similar to smoking cessation in that it is difficult in the short-term, but less so in the long-term,” and “while the discontinuation of opioid use is rarely possible for those addicted, it may be possible with support for those who are not addicted.”
To offer an interdisciplinary approach that reduces opioid dependence without negatively impacting pain outcomes, Ravi Prasad, PhD, Assistant Chief of Stanford’s Division of Pain Medicine, presented data from the inpatient Stanford Comprehensive Interdisciplinary Pain Program (SCIPP).
By providing physical and occupational therapy, encouraging lifestyle and behavioral modifications, and administering dosage-blind cocktails for medication optimization, Prasad said SCIPP produced significant improvements in pain levels, emotional functioning, and physical activity at discharge compared to admission.
“As we taper people off, it doesn’t mean that their functioning declines, provided we give them other tools to improve their functioning,” Prasad noted.
According to Darnall, a few of those tools include online mindfulness-based stress reduction and cognitive behavioral therapy resources, which she said “are not better than live therapy, but at least in an absolute pinch, you have places where you can send patients for self-management.”