Discontinuing Opioids in Patients With, Without Substance Use Disorders

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The most commonly prescribed pain medications during the year before discontinuation were hydrocodone, oxycodone, methadone, and morphine.
The most commonly prescribed pain medications during the year before discontinuation were hydrocodone, oxycodone, methadone, and morphine.

In a study of patients from the Veterans Health Administration, researchers found that most patients (85%) who discontinued long-term opioid use did so because of a clinician's, rather than the patient's decision.1

Of those patients, 75% were discontinued for diverging from the opioid course they should have been following. Those with substance use disorders (SUDs), most notably alcohol, were more likely to be discontinued from long-term opioids because of aberrant behaviors (81% vs 68%).

Travis I. Lovejoy, PhD, MPH, from the VA Portland Health Care System and Oregon Health & Science University and colleagues used the Veterans Health Administration Corporate Data Warehouse to identify a national cohort of Veterans Health Administration patients who were prescribed opioids throughout all of 2011.

From this cohort, the researchers randomly selected 300 patients with SUDs and propensity score-matched them with 300 patients without SUDs. They then conducted a comprehensive manual review of the patients' medical records to identify the reasons long-term opioids were discontinued.

Almost all the patients were experiencing musculoskeletal pain (86.0%), whereas some of the patients were experiencing pain from neuropathy (5.8%) or migraine headache (10.5%).

The most commonly prescribed pain medications during the year before discontinuation were hydrocodone (56.8%), oxycodone (37.7%), methadone (29.2%), and morphine (25.5%).

The researchers found that 85% of discontinuations were initiated by clinicians; 75% of clinician-initiated opioid discontinuations were a result of concerns about aberrant behavior, which included opioid misuse behaviors, substance abuse, and failure to adhere to a chronic pain treatment plan.

The American Pain Society and Veterans Affairs, jointly with the Department of Defense issued guidelines in 2009 and 2010, respectively to help clinicians identify high-risk behaviors in their patients that should prompt them to discontinue opioid treatments.2,3

In 15.2% of cases, reasons for discontinuing long-term opioids were patient-initiated. They included concerns about developing addiction or the belief that the patient was already addicted to opioids, concerns that the opioids were not effective at relieving their pain, adverse effects from the opioids, effective pain management with non-opioid options, or concerns from the patient's family members about their continued opioid use.

Challenges in Maintaining Positive Patient Relationships

Discontinuing long-term opioid therapy may damage the relationship between the patient and clinician. Indeed, as the researchers note,“Patient-centered models of care may be difficult to use in situations when patients perceive punitive action is being directed toward them.”

“The ways in which clinicians communicate with patients before, during, and after discontinuation of [long-term opioid therapy] are paramount to ensuring patients continue to receive pain care and other needed services rather than disengaging from a clinic or healthcare system entirely. If mishandled, patients may be at increased risk of engaging in illicit behaviors to obtain opioids, attempt to obtain opioids from other clinics or the emergency room, or resort to street drugs such as heroin,”the authors noted.

Long-term Opioid Therapy and SUD

There are many difficulties in navigating opioid therapy and SUD. On the 1 hand, in many patients with chronic pain, inadequately treated pain may lead to increased substance use or may lead to a patient relapsing into substance abuse after already being treated for it.

On the other hand, patients with substance use disorder are more likely to be put on an opioid regimen, despite being at higher risk for substance use-related overdose and death. The guidelines therefore recommend close monitoring of this patient subpopulation.

Long-term Opioid Therapy and Cannabis Use

Cannabis-positive test results accounted for close to half of aberrant urine drug tests detected, and although the researchers were unable to identify the reasons for patients' cannabis use in this study, they noted that some patients use cannabis to treat chronic pain. They also noted that at this time, 29 states and the District of Columbia allow cannabis for medical reasons, and that as this number grows, clinicians will be increasingly faced with inquiries from their patients regarding the inclusion of cannabis in pain management regimens. In addition, in the absence of relevant studies, clinicians will need to assess the efficacy and associated risks of treatment strategies combining opioids and cannabis.

Conclusions

Discontinuation of long-term opioid therapy is often initiated by clinicians in patients with SUDs or aberrant behaviors.

“Treatments that concurrently address [SUD] and chronic pain are needed for this high-risk population,” the researchers wrote. “Ensuring [that] patients have access after opioid discontinuation to non-opioid analgesic pharmacotherapies, non-pharmacologic pain management approaches, and [SUD] treatment is critically important, as inadequately treated pain can exacerbate other comorbid conditions — such as psychiatric disorders and [SUDs] — resulting in poorer quality of life. Integrating non-opioid pain therapies and [substance use disorder] treatment into multiple settings such as primary care and specialty [SUD] care is one possible approach.”

The investigators noted, however, that further research is needed to determine whether this treatment model would be effective for patients who discontinue long-term opioid therapy.

The researchers also wrote that their findings suggest that “a guideline-concordant universal precautions approach to urine drug testing in which all patients are randomly tested” may be necessary to accurately identify patients who misuse or abuse prescription medications or illicit substances.4

“Targeting urine drug testing to high-risk patients only, such as those with [SUD] diagnoses or other behaviors indicative of opioid misuse, will miss a substantial proportion of patients using substances,” the investigators wrote.

Disclosures: Dr Travis I. Lovejoy, Dr Joseph W. Frank, and Dr Steven K. Dobscha report grants from the US Department of Veterans Affairs during the conduct of the study.

 

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References

  1. Lovejoy TI, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Dobscha SK. Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain. 2017;158:526-534. doi:10.1097/j.pain.0000000000000796
  2. Cerda M, Bordelois PM, Keyes KM, Galea S, Koenen KC, Pardini D. Cumulative and recent psychiatric symptoms as predictors of substance use onset: does timing matter? Addiction. 2013;108:2119-2128.
  3. VA/DoD. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain. Washington, DC: Veterans Administration, 2010. Available at: http://www.va.gov/painmanagement/docs/cpg_opioidtherapy_fulltext.
  4. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-112.
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