OPIOID DOSE Reduction IN A CHRONIC PAIN POPULATION

  In an effort to combat the opioid epidemic the CDC has recommended limiting Morphine Dosing Equivalent to no more than 90 mg per day. Several authors note increased suicide rates concurrent with opioid dose reduction. Can we reduce opioid dosing safely in this population?

Our objectives included: (1) to reduce morphine equivalent dosing in chronic pain patients previously stable on more than 90 mg per day, (2) to track multiple factors during the reduction period, and (3) to evaluate the functional consequences of this opioid dose reduction in this population.

Chronic pain patients were slowly tapered down on their daily opiate dose 27% overall during approximately one years’ time while tracking self-reported sleep quality, anxiety, depression, suicidality, constipation, exercise and work participation hours, pain levels, body weight, and cognitive function. We found no significant changes in these measures in this population during the 18+ month’s study duration.

  Pain medication prescribing in the United States increased between 1999 and 2015 but has steadily decreased since. Unfortunately, opioid-related US overdose deaths continue to increase, averaging 130 per day in 2018, at which point opioid deaths were eclipsed by US suicide rate at 132 per day.

With passage of the Patient Protection and Affordable Care Act (PPACA) and its signing into constitutional law, electronic medical records implementation became law for 2014. This correlates temporally with the uptick in deaths attributed to Cocaine and Synthetic Opioids use (other than Methadone), now also surpassing opioid overdose–related deaths by prescription drug.

  It is concerning that several cases classified as opiate overdose deaths may actually besuicides: attempts to escape intractable pain. Other possibilities explaining increased suicide rate may include compromised care due to continued limitations in health care access (per US Census, uninsured rates increased from 7.9% to 8.5% between 2017 and 2018), now superimposed on mandated electronic health record use requiring providers to spend considerable time typing rather than either listening to or taking the time to interact more thoughtfully with their patients.

  Chronic pain patients on a stable opiate regimen in excess of 90mg morphine dose equivalent (MDE) per day were invited and encouraged to slowly taper and reduce their daily opiate dose over approximately one year (range 8-18 months). This was typically accomplished via a 5% reduction in total daily pain medication dose every other month.

Assessment of Pain Disability Index, PHQ-9, Generalized Anxiety Disorder-7, Epworth Sleepiness, and Suicide Behavior surveys, in addition to Trails-Making Test Performance (cognitive assessment), and self-reported Pain Levels, Sleep Hours, Constipation, Hours Exercise per week, and Hours Work per day were completed before and after opioid dose reduction window.

Statistical Analysis

Independent t-test using Baseline and Follow-up data (range 6-18 months duration) was conducted using all variables. Only one of the t-tests was significant (morphine reduction), suggesting overall alpha (re: type I error probability) was equal to or less than 0.05.

  Baseline Pain levels did not correlate significantly with intimacy suicidality, weight, or work levels. However, baseline pain levels did correlate statistically significantly and adversely with anxiety, depression, sleep quality, and pain disability index measures including participation with family activities, recreation, social, and self-care activities. 

Despite a 27% overall opiate dose reduction (from 236 mg to 173 mg MDE), there were no significant changes in the values closely monitored - nor suicide attempts occurring in this population (n=100) during the study period.

  Opiate dose reduction was not associated with increased measures of pain, anxiety, depression, pain disability index indices, sleep quality, self-care, suicidality, cognitive testing performance measures, or average weight. 

After study completion, one of the participants had surgery for a broken wrist - for which their pre-injury MDE opioid dose of 60 mg was increased to 75 mg/day post operatively. Patient’s dose was decreased by 24% two weeks later and patient attempted suicide by prescription drug overdose.

Careful opioid dose reduction (approx. 5% every other month) appears to have been well tolerated in this population. However, judicious monitoring during more aggressive opiate dose reduction is strongly recommended.

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