More than 50 million Americans live with chronic pain; among them, approximately one in 10 take prescription opioids regularly. A new large-scale study led by Stanford Medicine suggests that — with the right approach — many people may be able to reduce their opioid use long term without increasing their pain.
The key is a gradual approach to tapering opioid doses that puts the patient in the driver's seat.
"So much of the fear of opioid tapering is about losing control," said Beth Darnall , PhD, a professor of anesthesiology, perioperative and pain medicine and lead author of the study published July 7 in the Annals of Internal Medicine. "We tested a patient-centered methodology where we really focused on the individual patient and developed methods to ensure that they had maximal control in the process."
The study enrolled more than 500 adult patients who had pain for at least six months and taken prescription opioids for at least three months. (On average, the participants had taken opioids for 12.4 years.) Patients worked with their clinicians to create a personalized opioid tapering plan with the goal of achieving their lowest comfortable opioid dose over 12 months. Doses were reduced no more than 10% per month, and patients could control the pace of their taper and pause the taper in collaboration with their clinician.
After 12 months, about half of patients achieved a successful response, defined as cutting their opioid dose by at least 50% without increased pain or staying at the same dose with significantly less pain.
"For patients, I think the data are reassuring that if opioids are tapered the right way, meaning a patient-centered approach, people can significantly reduce their opioid doses without having increased pain long term," Darnall said.
The tapering program is not designed for people who have an addiction to opioids, she added, and patients with moderate or severe opioid use disorder were excluded from the study. Many people who take opioids long-term develop physiological dependence to the medications — and experience withdrawal symptoms when the medication is reduced — but do not meet other criteria for addiction, which include taking more than prescribed, drug-seeking behavior, and negative impacts on work and social life.
The study also compared the impact of two behavioral supportive therapies for pain management offered on top of the patient-centered tapering plan. One-third of participants were randomly assigned to receive eight weekly sessions of cognitive behavioral therapy for chronic pain, which focused on psychological skills to understand and ease pain. Another third were randomly assigned to receive six weekly sessions of a peer-led chronic pain self-management program, which included education on pain management, nutrition and communication with clinicians. Another third received only the patient-centered tapering plan.
The researchers found that the addition of supportive therapies did not boost the success rate of opioid tapering, but cognitive behavioral therapy for chronic pain seemed to lessen opioid withdrawal symptoms.
Tapering too fast
The patient-centered approach to opioid tapering is in line with current recommendations from the Centers for Disease Control and Prevention, but that was not always the case.
Through the late 1990s and 2000s, a surge in opioid prescribing for chronic pain contributed to a rise in addiction, overdose and other health complications. In response, in 2016, the CDC released opioid prescribing guidelines that emphasized the need to reduce opioid doses but without clear guidance on how to taper.
"What ended up happening was that after the publication of the 2016 guidelines, there was rapid deprescribing, meaning there were people who had been taking opioids for a long time who were tapered too fast," Darnall said.
Some patients were cut off abruptly and without their consent. For some, the ensuing mental distress and severe opioid withdrawal symptoms led to suicidal behavior or overdose from illicit drugs.
"Ironically, in the name of reducing their risk, we were creating new risks by reducing opioids in the wrong way," Darnall said. "The data told us that there are risks when you go up on doses, but there are risks when you go on down on doses, too."
Patient-centered approach
At the time, most studies on opioid tapering focused on inpatient settings, but as a pain psychologist, Darnall had long heard from her chronic pain patients that many wanted to reduce their opioid dose but didn't know how. In 2018, she and her collaborators published a small, four-month study showing that a slow, individually designed taper could help many patients at a community pain clinic lower their opioid dose.
The new study expands on that work, recruiting patients from 11 primary care and pain clinic sites in five states. Patients met with their clinician every three to four weeks, either in person or online. Integral to the patient-centered approach was an electronic platform, called CHOIR, developed by Sean Mackey , MD, PhD, the Redlich Professor, chief of the Division of Pain Medicine and member of the study's executive research team. It automated weekly and monthly check-ins with the patients and responded with recommendations and compassionate messages.
"If they reported having major distress or major symptoms, that would get escalated to the clinic so the doctor would know and be communicating with the patient quickly," Darnall said.
The platform also included an opioid tapering calculator that recalibrated the personalized plan based on tapering decisions made throughout the year.
The researchers hope that these electronic tools can help more clinicians implement patient-centered opioid tapering.
"We're making available to the public our opioid tapering calculator, which we developed as part of this study, and the entire CHOIR informatics platform, which can monitor patients and provide automated support," Darnall said. "We're making it available for free, but it still requires that health care systems dedicate resources to integrate it into their system."
Easing withdrawal symptoms
The CDC updated its opioid prescribing guidelines in 2022 to encourage more individualized care and shared decision-making with the patient, and to warn against rapid tapering. It also suggests that integrating behavioral support therapies into the tapering process could improve outcomes.
The new study is the first to compare tapering programs with and without behavioral support therapies, though the results were not what the researchers expected.
"When we originally conceptualized this study, we thought that if we apply these two behavioral interventions, maybe patients will reduce their doses more and have less pain, and we didn't find that," Darnall said. In fact, the groups assigned the supportive therapies had slightly lower rates of tapering success — 48.6% for the cognitive behavioral therapy for pain group and 44.5% for the chronic pain self-management program, compared with 50.9% for the taper-only group.
Participation in the supportive therapies was relatively low, with only about 60% of participants attending any of their assigned sessions, perhaps because the tapering program was already time intensive.
But when the team analyzed the results, they found that patients in supportive therapy groups experienced fewer opioid withdrawal symptoms. In particular, those assigned to cognitive behavioral therapy for chronic pain reported about half as many withdrawal symptoms as those in the taper-only group.
The researchers also noted that a patient's self-rated "readiness" to taper at the start of the study was a good predictor of taper success, underscoring the importance of allaying patients' fears and giving them a sense of control.
Before embarking on the study, Darnall's team surveyed hundreds of patients and found that 68% of patients on prescription opioids had tried tapering without success. Most had attempted on their own, sometimes cold turkey.
"If they stop abruptly, it's probably going to be a horrible experience," Darnall said. "So that's the experience they have and they think, 'I need to stay on my dose; I can't taper opioids.' But often that's not true — it was a flawed experiment."
Researchers from the University of Arizona College of Medicine, Vi Palo Alto, Jonathan M. Wainwright Memorial Veterans Affairs Medical Center, University of the Pacific, University of Maryland School of Nursing, Kaiser Permanente, MedNOW Clinics, Lehigh Valley Physician Group, Intermountain Health and Stieg Clinics also contributed to the work.
The study was supported by funding from the Patient-Centered Outcomes Research Institute (PCORI).
