Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy A Systematic Review

被引:254
作者
Frank, Joseph W. [1 ]
Lovejoy, Travis I. [3 ]
Becker, William C. [2 ]
Morasco, Benjamin J. [4 ]
Koenig, Christopher J. [5 ]
Hoffecker, Lilian [6 ]
Dischinger, Hannah R. [7 ]
Dobscha, Steven K. [8 ]
Krebs, Erin E. [9 ]
机构
[1] VA Eastern Colorado Hlth Care Syst, 1055 Clermont St, Denver, CO 80220 USA
[2] VA Connecticut Healthcare Syst, 950 Campbell Ave,Mail Stop 151B, West Haven, CT 06516 USA
[3] VA Portland Hlth Care Syst, Ctr Improve Vet Involvement Care, 3710 SW US Vet Hosp Rd,Mail Code R&D 66, Portland, OR 97239 USA
[4] VA Portland Hlth Care Syst, Ctr Improve Vet Involvement Care, 3710 SW US Vet Hosp Rd,Mail Code R&D 99, Portland, OR 97239 USA
[5] San Francisco State Univ, Dept Commun Studies, 1600 Holloway Ave,Humanities Bldg,Room 282, San Francisco, CA 94132 USA
[6] Univ Colorado, Hlth Sci Lib, 12950 East Montview Blvd,MS-A003, Aurora, CO 80045 USA
[7] Oregon Hlth & Sci Univ, Sch Med, 3181 SW Sam Jackson Pk Rd, Portland, OR 97239 USA
[8] VA Portland Hlth Care Syst, Ctr Improve Vet Involvement Care, 3710 SW US Vet Hosp Rd, Portland, OR 97239 USA
[9] Minneapolis Vet Affairs Hlth Care Syst, Ctr Chron Dis Outcomes Res, One Vet Dr, Minneapolis, MN 55417 USA
关键词
CHRONIC NONCANCER PAIN; COGNITIVE-BEHAVIORAL THERAPY; PRIMARY-CARE; REHABILITATION PROGRAM; MINDFULNESS MEDITATION; ANALGESIC MEDICATION; COMPREHENSIVE PAIN; OPIATE REDUCTION; UNITED-STATES; WITHDRAWAL;
D O I
10.7326/M17-0598
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background: Expert guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT) when risks outweigh benefits, but evidence on the effect of dose reduction on patient outcomes has not been systematically reviewed. Purpose: To synthesize studies of the effectiveness of strategies to reduce or discontinue LTOT and patient outcomes after dose reduction among adults prescribed LTOT for chronic pain. Data Sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through April 2017; reference lists; and expert contacts. Study Selection: Original research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain. Data Extraction: Two independent reviewers extracted data and assessed study quality using the U.S. Preventive Services Task Force quality rating criteria. All authors assessed evidence quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Prespecified patient outcomes were pain severity, function, quality of life, opioid withdrawal symptoms, substance use, and adverse events. Data Synthesis: Sixty-seven studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions, were found. Study quality was good for 3 studies, fair for 13 studies, and poor for 51 studies. Many studies reported dose reduction, but rates of opioid discontinuation ranged widely across interventions and the overall quality of evidence was very low. Among 40 studies examining patient outcomes after dose reduction (very low overall quality of evidence), improvement was reported in pain severity (8 of 8 fair-quality studies), function (5 of 5 fair-quality studies), and quality of life (3 of 3 fair-quality studies). Limitation: Heterogeneous interventions and outcome measures; poor-quality studies with uncontrolled designs. Conclusion: Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue LTOT and that pain, function, and quality of life may improve with opioid dose reduction.
引用
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页码:181 / +
页数:29
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