PAIN REDUCTION WITH OPIOID ELIMINATION

Edward Covington, MD, Cleveland Clinic Foundation; Margaret Kotz, DO, Cleveland Clinic Foundation The last decade has seen a reversal of the historical belief that chronic opioid therapy (COT) was inadvisable in nonmalignant palm. Numerous studies demonstrate sustained pain reduction with chronic opioid therapy; however, there are clinical reports and animal models that suggest chronic opioids may at times exacerbate pain. Clearly, many patients without apparent structural deficit have persistent pain and dysfunction despite high dose opioid therapy. Thus, while opioids have been shown to be safe in long term use, the question of efficacy remains. Predictors of success in COT are not fully established. Studies of intrathecal opioids suggest that high levels of patient satisfaction and retrospective reports of benefit may occur despite minimal change in pain level and function. This raises the question of whether at times the purported benefits of long‐term opioid therapy may be illusory. Consecutive admissions to a chronic pain rehabilitation program (n = 228) were studied. This program represents a biased population in that many referrals have dysfunction that is discordant with pathology, inordinate suffering and dysphoria, poorly explained pain, or substance use problems. Of 228, 56 were taking ≥ 100 mg p.o. morphine equivalents/d on admission (mean 456 mg/d). Data are available on 46 of these receiving ‘high dose’ opioids. Patients participated in a rehabilitation program that included reconditioning, cognitive behavioral psychotherapy, adjuvant medications, and elimination of opioids and benzodiazepines. 43 (93%) experienced a reduction in pain with opioid elimination (from 7.2 to 4.0/10). Three experienced an increase in pain. Depression and functional impairment also improved. Cases will be presented of patients who believed they were benefiting from chronic opioid therapy, but improved after opioid elimination. They commonly described “getting myself back” after elimination of opioids. Physiological considerations and treatment implications will be described.