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The opioid crisis emerged in part due to the overprescribing of opioid analgesics for chronic pain. Although not the only source of the current epidemic of opioid use disorder (OUD), the prescription of opioids for chronic pain remains one vector for the development of opioid misuse and OUD. However, opioid tapering is not appropriate for all patients, and some patients may need to remain on opioid therapy for the long term. To reduce the risk of opioid‐related harm among people with chronic pain and to treat incipient or entrenched addictive behaviours, new interventions are needed. This review discusses the clinical outcomes, biobehavioural mechanisms and implementation considerations for a novel, evidence‐based intervention for chronic pain, opioid use and OUD called Mindfulness‐Oriented Recovery Enhancement (MORE). MORE unites complementary aspects of mindfulness training, cognitive behavioural therapy and principles from positive psychology to simultaneously address addictive behaviour, emotion dysregulation and chronic pain by targeting brain reward and stress systems. MORE has been tested in 13 completed randomized clinical trials, including over 1300 patients, and has demonstrated efficacy against a range of active control conditions for reducing opioid dosing, opioid misuse, illicit drug use, depression, post‐traumatic stress symptoms and chronic pain. Opportunities for implementing MORE include facilitating opioid tapering and promoting safe opioid use in primary care and specialty pain clinics, decreasing opioid misuse and enhancing medication‐assisted treatment for OUD. Given evidence of MORE's efficacy, it is now time to consider disseminating this evidence‐based treatment in the United States, the United Kingdom and worldwide. [ABSTRACT FROM AUTHOR]

This article discusses the controversy surrounding pre-operative opioid tapering and its potential to advance personalized, patient-centered pain medicine. The use of opioids for chronic non-cancer pain management is common, but it is associated with negative outcomes in the peri-operative period, such as respiratory failure and surgical site infections. The article presents the findings of a pilot study that assessed the feasibility of a pharmacist-led opioid tapering program before elective hip or knee arthroplasty. The study found high adherence to the program and positive outcomes in terms of physical functioning and quality of life. However, the study has limitations, and further research is needed to determine the effectiveness of pre-operative opioid tapering in a broader patient population. [Extracted from the article]

Background: Opioid tapering and discontinuation have increased in recent years with the implementation of national prescribing guidelines. This study aimed to examine the relationship between opioid tapering velocity and mental health crisis events in older Medicare beneficiaries. Methods: A nested case–control study was conducted using the 2012–2018, 5% national Medicare claims data. Older adults with chronic non‐cancer pain (CNCP) who were receiving long‐term opioid therapy (LTOT) were included in the study. Cases were defined as individuals experiencing mental health crisis events; controls were identified using incidence density sampling. The opioid tapering velocity was measured in the 120‐day hazard period that yielded a monthly percentage of dose change. Conditional logistic regression was used to assess the relationship of interest. Results: A total of 42 091 older adults with CNCP were eligible for the study. Cases (n = 952) were matched with controls in a 1:2 ratio based on age (±1 year) and time of cohort entry (±30 days). A higher percentage of controls (67.65%) were on steady dose compared with cases (59.03%). In the adjusted model, tapering (aOR = 1.36; 95% CI: 1.02–1.83), rapid tapering (aOR = 1.45; 95% CI: 1.11–1.91), and dose escalation (aOR = 1.78; 95% CI: 1.32–2.39) were significantly associated with the mental health crisis, compared with steady dose. Conclusion: Both opioid tapering and dose escalation are associated with mental health crisis events. Patient‐driven and gradual dose tapering, as recommended by prescribing guidelines, should be promoted to prevent mental health crisis events among older adults on LTOT. [ABSTRACT FROM AUTHOR]

Background: Persistent opioid use following surgery is common especially in patients with preoperative opioid use. This study aims to determine the long‐term effect of an individualised opioid tapering plan versus standard of care in patients with a preoperative opioid use undergoing spine surgery at Aarhus University Hospital, Denmark. Methods: This is the 1‐year follow‐up of a prospective, single‐centre, randomised trial of 110 patients who underwent elective spine surgery for degenerative disease. The intervention was an individualised tapering plan at discharge and telephone counselling 1 week after discharge, compared to standard of care. Postoperative outcomes after 1 year include opioid use, reasons for opioid use and pain intensity. Results: The overall response rate to the 1‐year follow‐up questionnaire was 94% (intervention group 52/55 patients and control group 51/55 patients). Forty‐two patients (proportion = 0.81, 95% CI 0.67–0.89) in the intervention group compared to 31 (0.61, 95% CI 0.47–0.73; p =.026) patients in the control group succeeded in tapering to zero 1 year after discharge (p =.026). One patient (0.02, 95% CI 0.01–0.13) in the intervention group compared to seven patients (0.14, 95% CI 0.07–0.26) in the control group were unable to taper to their preoperative dose 1 year after discharge (p =.025). Back/neck and radicular pain intensity was similar between study groups. Conclusion: These results suggest that an individualised tapering plan at discharge combined with telephone counselling 1 week after discharge can reduce opioid use 1 year after spine surgery. [ABSTRACT FROM AUTHOR]

Background: Ketamine, a potent analgesic and N‐methyl‐D‐aspartate‐(NMDA)‐receptor antagonist, improves analgesic outcomes in patients with complex regional pain syndrome (CRPS). The NMDA receptor has also been implicated in opioid withdrawal. The use of ketamine to assist with a rapid opioid taper in the setting of CRPS has not been previously described. Case: We present a case in which a 5‐day continuous ketamine infusion was utilized in a robust multimodal analgesia regimen in combination with cognitive behavioral therapy (CBT) to successfully taper a patient with complex regional pain syndrome (CRPS) who was taking 330 mg of daily morphine equivalents completely off of opioids, minimize withdrawal symptoms, and produce sustained results. Discussion: CRPS may involve catecholamine hypersensitivity and central sensitization and can be notoriously challenging to treat by itself even outside of the context of an opioid taper. The patient we describe here received one additional 5‐day infusion at 6 months and remained opioid‐free while experiencing a major improvement in function and lifestyle that he still maintains. This was possible through a combination of aggressive inpatient management with ketamine as the centerpiece, followed by consistent outpatient CBT to maintain results without the need for a return to opioids. This combination has previously not been described in the setting of a rapid opioid taper and this patient's underlying CRPS made it all the more remarkable. [ABSTRACT FROM AUTHOR]