Research Finds Less Opioids Often Better Than More

Research Finds Less Opioids Often Better Than More

Two research programs looking at chronic pain patients who are unsatisfied with their opioid pain management may offer some relief not only for patients, but also for frustrated pain management clinicians looking for solutions.

The two studies may also help explain phenomena encountered by professionals in the recovery industry.

Today, against the backdrop of our national "opioid crisis," we have the too-often clash of wills between upset patients who still hurt, and their nurses or physicians who struggle daily with current opioid prescribing guidelines that don't quite fill the bill for such patients.

One research program, at Duke University, has confirmed that the vast majority of complaints of dissatisfaction come from post-surgical patients who were already opioid-tolerant* upon admission. Such complaints are a familiar refrain to clinicians everywhere. However, no standard, effective medical response has been widely accepted and adopted.

In the other program, at Kaiser Permanente, the majority of opioid-tolerant patients - those who have taken high doses of opioid painkillers for long periods – are satisfied when their doctors "taper," or gradually lower, their opioid dosages.

This study of outpatients, not hospital inpatients, also found slightly less dissatisfaction when patients were dealing with their familiar primary care provider, compared to "encounters between patients and an unassigned provider."

These seemingly disparate findings may yet offer a clue to the ever-present problem of chronic pain versus opioid dependence, addiction, and overdose.

The Duke Study

The Duke University study looked at 60,000 patient records at three Duke medical facilities and found the phenomenon of dissatisfaction from opioid-tolerant patients is predictable.

According to Neil Ray, MD, assistant professor of anesthesiology at Duke University School of Medicine, in Durham, N.C., 4%, 6% and 7% of patients arriving at the three institutions were high-dose opioid tolerant at the time of admission. Low satisfaction scores from these patients were consistent across all three facilities.

Such patients report worse pain management scores than patients not previously taking opioids. In addition, they not only complain of under-managed pain, they experience prolonged length of stay, more adverse events, and increased re-admissions.

The Duke project also revealed a "dose-response relationship" between patient satisfaction and opioid dose at the time of admission. The higher the dose prescribed to the patient, the greater was the patient's dissatisfaction.

The Kaiser Study

The Kaiser Permanente study looked at 2,492 patient encounters involving high-dose chronic opioid use for noncancer pain. Opioids were reduced at 29% of those encounters. Most of these - 86.4% - resulted in favorable satisfaction scores, the researchers said.

Additionally, the study found that satisfaction scores were higher when the patient's own primary provider managed tapering. Unassigned providers were associated with slightly lower satisfaction scores.

"Physicians are often concerned they will receive lower satisfaction scores if they reduce opioids for patients who are accustomed to high opioid doses to manage chronic pain," said lead study author Adam Sharp, MD, MS. "This study showed that following current recommendations and reducing opioids for chronic pain did not result in lower satisfaction scores."

What's it all mean?

In the Duke study, we see that opioid-tolerant patients complain more about their pain than do non-tolerant patients. In addition, the more opioids prescribed, the worse the satisfaction scores. At Kaiser, most patient satisfaction scores remained high during and after opioid dose tapering, and they were even better when managed by the primary care doctor.

It is important to keep in mind that these two patient groups - post-surgical patients at Duke, and chronic pain patients at Kaiser - are distinctly different.

However, the idea here is that anyone on a high-dose opioid regimen for non-cancer chronic pain who is thinking about reducing their opioid dosage, or getting off opioids altogether, might take a lesson from these studies. That goes for physicians and other caregivers as well.

Opioid-tolerant or dependent patients headed to elective surgery would do better with some dedicated opioid tapering a la the Kaiser study well before surgery. Coupled with the use of adjuvant non-opioid analgesics pre- and post-surgically, we might see a definite change in pain management scores right across the boards.

One final note: Perhaps physicians should routinely investigate the phenomenon called "opioid-induced hyperalgesia" - increased sensitivity to pain caused by opioids. It is a very real problem and too often overlooked.

*The FDA defines a patient as opioid tolerant if for at least 1 week he or she has been receiving oral morphine 60 mg/day; transdermal fentanyl 25 mcg/hour; oral oxycodone 30 mg/day; oral hydromorphone 8 mg/day; oral oxymorphone 25 mg/day; or an equianalgesic dose of any other opioid. Opioid tolerance implies a lesser susceptibility to the effects of opioids-both therapeutic and adverse-and it may develop in individuals with long-term use of opioids. Patients who are prescribed opioids for management of cancer pain or chronic noncancer pain or who have an opioid addiction may become opioid tolerant. (from

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