Opioid tapering may improve outcomes for chronic pain sufferers

July 11, 2017

1. Opioid tapering may improve outcomes for chronic pain sufferers
Abstract: http://annals.org/aim/article/doi/10.7326/M17-0598
Editorial: http://annals.org/aim/article/doi/10.7326/M17-1402
URLs go live when the embargo lifts

Dose reduction may improve pain, function, and quality of life for patients prescribed long-term opioid therapy for chronic pain. Results of a systematic evidence review are published in Annals of Internal Medicine.

Approximately 10 million U.S. adults are prescribed long-term opioid therapy for chronic pain. This dramatic increase in opioid prescribing has been accompanied by increases in opioid overdose. Expert guidelines recommend reducing or discontinuing long-term opioid therapy when risks outweigh the benefits, but evidence on the effects of dose reduction on patient outcomes had not been systematically reviewed.

Researchers at the Veterans Health Administration conducted a systematic review of 67 published studies to determine the effectiveness of strategies to reduce or discontinue long-term opioid therapy prescribed for chronic pain and the effect of dose reduction or discontinuation on important patient outcomes. While the overall quality of the evidence was very low, fair-quality studies showed that opioid dose reduction was associated with improvements for outcomes such as pain, function, and quality of life.

The authors noted that there was inadequate evidence to assess the risks of opioid dose reduction. They recommended that, when possible, opioid tapering should be accompanied by multidisciplinary pain programs that incorporate behavioral interventions, such as cognitive behavioral therapy or mindfulness meditation.

Editorialists from the Centers for Disease Control and Prevention (CDC) caution that decisions to discontinue or reduce long-term opioid therapy should be made together with the patient. Clinicians have a responsibility to carefully manage opioid therapy and not abandon patients in chronic pain. The CDC offers several resources to help physicians in primary care practice navigate pain management and tapering of opioid therapy.

Media contact: For an embargoed PDF, please contact Cara Graeff at cgraeff@acponline.org. For an interview with the lead author, Joseph W. Frank, MD, MPH, please contact Mark Couch at mark.couch@ucdenver.edu or 303-724-5377. To speak with Deborah Dowell, MD, MPH from the CDC, please contact Courtney Lenard at zvq5@cdc.gov or 770-488-3733.

2. The 'pharmaceuticalization' of tobacco threatens public health
Abstract: http://annals.org/aim/article/doi/10.7326/M17-0759
URLs go live when the embargo lifts

The reinvention of the tobacco industry as a pharmaceutical company-like purveyor of "safer" tobacco and smoking cessation products is a threat to public health, suggests a commentary published in Annals of Internal Medicine. The authors warn that this type of opportunistic transition, known as pharmaceuticalization, may fundamentally change how policymakers and the public perceive both the tobacco industry and its products.

Pharmaceuticalization is potentially dangerous because it intertwines two false assumptions: For a substantial number of smokers the habit is too ingrained for them to quit, and most smokers who want to quit require pharmacotherapy to do so. These premises are self-serving, as they may guide policy away from prevention or complete cessation, supporting prolonged use of safer nicotine products.

In addition to policy implications, pharmaceuticalization also poses three important health consequences. First, it dilutes and diminishes the process and trust associated with the approval of real pharmaceuticals. Second, it complicates and lessens the regulatory process, as new tobacco drugs and devices are not subjected to the same scrutiny as prescription drugs. And third, pharmaceuticalization legitimizes the tobacco industry.

Through pharmaceuticalization, big tobacco seeks to rehabilitate its image. By seeming responsive to public health concerns, tobacco companies seem to exonerate themselves from the responsibility of having addicted smokers in the first place.

Media contact: For an embargoed PDF, please contact Cara Graeff at cgraeff@acponline.org. For an interview with the lead author, Pamela M. Ling, MD, MPH, please contact Elizabeth Fernandez at elizabeth.fernandez@ucsf.edu or 415-514-1592.

Also new in this issue:

The Opioid Epidemic: What's a Hospitalist to Do?

Pooja Lagisetty, MD, MSc, and Amy Bohnert, PhD

Annals for Hospitalists

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1564

American College of Physicians

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