• Joseph W Frank, Travis I Lovejoy, William C Becker, Benjamin J Morasco, Christopher J Koenig, Lilian Hoffecker, Hannah R Dischinger, Steven K Dobscha, and Erin E Krebs.
• From VA Eastern Colorado Health Care System, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado; VA Portland Health Care System and Oregon Health & Science University, Portland, Oregon; VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut; San Francisco State University, San Francisco, California; and Minneapolis VA Health Care System and University of Minnesota Medical School, Minneapolis, Minnesota.
• Ann. Intern. Med. 2017 Aug 1; 167 (3): 181-191.

BackgroundExpert 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.PurposeTo 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 SourcesMEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through April 2017; reference lists; and expert contacts.Study SelectionOriginal research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain.Data ExtractionTwo 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 SynthesisSixty-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).LimitationHeterogeneous interventions and outcome measures; poor-quality studies with uncontrolled designs.ConclusionVery 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.Primary Funding SourceVeterans Health Administration. (PROSPERO: CRD42015020347).

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