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Stopping long-term opioid therapy has no effect on pain

Findings have significant implications for opioid conversations between patients and their providers
Prescription Medicine
Patients who discontinue using opioids did not experience increased pain levels. In fact their pain levels remained the same or slightly improved compared to pain before they stopped using opioids. (Getty Images)

Patients may experience no discernible difference in their level of pain after discontinuing the long-term use of opioids, new research suggests.

Researchers examined the electronic health records of 600 patients in a national database maintained by the U.S. Department of Veterans Affairs. They found that patients, on average, experienced no difference in pain after they discontinued long-term use of opioids.

“Our data suggest that patients who discontinue opioid therapy will not experience worse pain,” the authors write. “Rather, their pain will remain similar or slightly improve, on average, relative to their levels of pain prior to discontinuation.”

The findings will be presented at the annual meeting of the Society of Behavioral Medicine April 11-14 in New Orleans.

dark haired man, smiling at camera
Travis Lovejoy, Ph.D., M.P.H.

“This has the potential of adding to the pendulum swinging to get people off opioids,” said corresponding author Travis Lovejoy, Ph.D., M.P.H., an assistant professor of psychiatry in the OHSU School of Medicine and a clinical psychologist in the VA Portland Health Care System.

The national opioid epidemic took hold in the 1990s, with an increased focus on helping patients to manage chronic pain. Pharmaceutical companies began marketing opioids to treat chronic pain beyond its previously established use in cancer treatment, palliative care and end-of-life care. However, widespread use of prescription opioids led to problems of misuse, addiction and overdoses. In 2016 alone, more than 60,000 people died from overdoses in the United States.

New prescribing guidelines are calling for physicians to reduce the use of opioids, yet little empirical data are available to gauge the long-term effect of opioids in pain management.

Lovejoy and fellow researchers from OHSU and Washington State University examined the health records of patients who had been on long-term opioid therapy and then discontinued for at least 12 months. The bulk of the patients suffered from chronic musculoskeletal pain and half were diagnosed with substance use disorder. The researchers then plotted each patient’s self-reported pain intensity scores for 12 months before and 12 months after their opioid therapy.

Although pain intensity fluctuated widely across time, discontinuing opioids appeared to make no difference for patients’ pain level plotted on average.

“Average pain intensity does not significantly worsen in the 12 months after discontinuation, and for some patients may in fact improve,” the authors write.

While the findings are striking – opioids appear to provide little benefit with significant harm in terms of the risk of addiction and overdose – Lovejoy cautioned that simply cutting off opioids may lead to other outcomes that weren’t measured in the study. For example, patients could migrate to another provider outside the VA system, they could experience suicidal ideation or they could seek illicit substances such as heroin.

“There’s still a lot to learn about the potential adverse effects of taking patients off opioids,” said lead author Sterling McPherson, Ph.D., associate professor and director of biostatistics and clinical trial design at Washington State University Elson S. Floyd College of Medicine. “While there is a current push for policy change and legislation regarding opioids, we still don’t fully understand the impact of taking patients off of long-term opioid therapy for treating chronic pain.”

Lovejoy said the next phase of research will enroll more than 1,000 patients and track them over time through survey methodologies and follow-up interviews to understand patients’ experiences with the opioid discontinuation process. In the meantime, he said, the new research may help patients gain a better understanding of their pain with and without opioids.

“These data might help to normalize people’s pain experience and educate them about the reality of their pain,” Lovejoy said. “We found that their pain doesn’t change. What we infer from that is, for people with chronic pain, it’s never going to go to zero. Rather, it will continue to fluctuate over time as it did when they were still on opioids.”

The study comes on the heels of the results of a randomized clinical trial published in the Journal of the American Medical Association on March 6, which compared opioids and non-opioid treatment over 12 months for chronic back pain or hip or knee osteoarthritis pain. That study found that opioids did not provide better pain relief than non-opioid alternatives such as acetaminophen.

The new study adds to the pool of knowledge about the effectiveness of opioids.

“Our findings, coupled with existing evidence on the long-term effectiveness of opioid therapy to reduce pain intensity, have significant clinical implications for the ways in which opioid discontinuation processes and conversations take place between patients and clinicians,” the authors write.

Research was supported by a center grant to Lovejoy and co-author Sterling McPherson, Ph.D., of Washington State University from the U.S. Department of Veterans Affairs Health Services Research & Development Center to Improve Veteran Involvement in Care at the VA Portland Health Care System and locally initiated project award QLP 59-048 from the VA’s Substance Use Disorder Quality Enhancement Research Initiative. Lovejoy received additional support from Career Development Award IK2HX001516 from the VA Health Services Research and Development Center.

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