This review (based on low-quality evidence) came to the unlikely conclusion that their hypothesis is true: pain doesn’t increase (and sometimes even decreases) when opioids are tapered.
Considering that people are committing suicide due to pain when their opioids are tapered, this study’s findings fly in the face of reality. But people (and our doctors) who read such “research” papers then end up believing this heavily biased nonsense.
To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.
Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels.
Among many other flaws of this review, the language mixes up the classifications of “levels of evidence” with “types of study”.
There are 5 levels of Evidence:
Levels of Evidence for Therapeutic Studies*
|1A||Systematic review (with homogeneity) of RCTs|
|1B||Individual RCT (with narrow confidence intervals)|
|1C||All or none study|
|2A||Systematic review (with homogeneity) of cohort studies|
|2B||Individual Cohort study (including low quality RCT, e.g. <80% follow-up)|
|2C||“Outcomes” research; Ecological studies|
|3A||Systematic review (with homogeneity) of case-control studies|
|3B||Individual Case-control study|
|4||Case series (and poor quality cohort and case-control study|
|5||Expert opinion without explicit critical appraisal or based on physiology bench research or “first principles”|
*From the Centre for Evidence-Based Medicine, http://www.cebm.net.
There are 4 levels of Grade Practice Recommendations, graded on what levels of evidence were used.
Grade Practice Recommendations*
|Grade||Descriptor||Qualifying Evidence||Implications for Practice|
|A||Strong recommendation||Level I evidence or consistent findings from multiple studies of levels II, III, or IV||Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present|
|B||Recommendation||Levels II, III, or IV evidence and findings are generally consistent||Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preferences|
|C||Option||Levels II, III, or IV evidence, but findings are inconsistent||Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role|
|D||Option||Level V evidence: little or no systematic empirical evidence||Clinicians should consider all options in their decision making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role|
So, they start with shaky evidence from studies that didn’t specifically address the pain levels after opioid tapering, and then…
Characteristics of the studies were abstracted into tabular form for numerical analysis.
This adds another layer of interpretation and opinion to the outcome of this review. “Characteristics of the studies were abstracted” is so vague as to be almost meaningless.
I can see that anyone who approaches this research with an anti-opioid mindset can easily “abstract” the data from other studies in a manner that supports their prejudiced viewpoint.
Studies were rated independently by two reviewers for quality.
The percentage of studies supporting the above hypothesis was determined.
- No studies had a rejection quality score.
- Combining all studies, 2,109 CPPs were tapered.
- Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically.
- In 15% of the studies, pain was the same by taper completion.
- One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%.
- As such, 100% of the studies supported the hypothesis.
Who are these people whose pain *improves* when opioids are tapered?
I’m totally baffled by these findings because I and other pain patients I know definitely have worse pain with less opioid medication. Most of us take as few pills as we can get away with to save them for pain flares when we need extra.
My pain doctor had been losing patience with me because every alternative treatment she suggested didn’t work. I tired each one with new hope and enthusiasm, believing it could reduce my pain as it had for so many of her other patients, but I found no success.
Then I had a disastrous appointment with her when I asked for extra medication because my regular monthly prescription was going to run out during a 2-week visit to my mother. I was shocked when she suddenly snarled at me, “I know exactly what’s going on here!”
Well, she obviously didn’t, but at that point, she decided I was seeking opioids for “fun”. This meant she would no longer believe and trust me, so there was no point in seeing her any longer and I went back to my PCP.
For 3 months, I tried tapering myself in preparation for being cut off and found myself much less functional, both physically and mentally. I didn’t notice withdrawals at all, perhaps because I was so depressed and anxious about losing my access to the medication that allowed me a decent quality of life.
Instead of “puttering around the house”, I had to stay lying down on the couch. Instead of walking the dogs a mile, I only took them about 1/4 mile. I wasn’t able to do my writing because the pain became intense enough to constantly interrupt whatever I was doing. Even reading anything that required concentration was difficult.
So I do not understand why so many people in these studies *seem* to suffer no increased pain when they stop taking opioids. From what I’ve seen published as “research” these days, it’s clear that results can be tweaked to create the desired “finding”, so I suspect that a closer inspection of the study might arrive at a different result.
There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain.
However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data.
Yet, these shortcomings didn’t impede the publication of this study. Many research “reviews” about opioids seem to include studies with “evidence being marginal in quality with large amounts of missing data”.
The following table shows how marginal “type 3 and 4 study evidence” is:
IA Evidence from meta-analysis of randomized controlled trials IB Evidence from at least one randomized controlled trial IIA Evidence from at least one controlled study without randomization IIB Evidence from at least one other type of quasi-experimental study III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies IV Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both
As long as they support the “opioids are evil” storyline, studies are designed and published no matter how defective they are, but I’m sure they would be excluded if the results showed a benefit from opioids.
These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
This must have been a type 3 study, using the least dependable data.