Re: Effects of Implementing a Comprehensive Opioid Reduction Protocol on Overall Opioid Prescribing Among Patients with Chronic, Non-Cancer Pain in a Rural Family Medicine Clinic: A Controlled Crossover Trial

To the Editor: Stack et al¹ describe a comprehensive opioid reduction protocol in patients with chronic noncancer pain conducted by Family Medicine providers in a rural community. Although the authors describe a multifaceted approach with medical and psychoeducational components, 1 key element is missing: the patient experience. Exclusion of patient function is mentioned as a limitation of the study, but the importance of the patient perspective as it pertains to opioid reduction, functional assessment, and pain is minimized. Comprehensive care of the patient with chronic noncancer pain should incorporate a patient-centered plan, which must include functional assessment and long-term followup.

Opioids are dangerous medications with myriad side effects.² Tapering opioids too quickly can result in withdrawal symptoms and return of pain. Implementation of a functional pain scale, like the Brief Pain Inventory,³ would objectively assess both the patients’ experiences and the protocol’s sustainability. Although this tool was originally constructed to assess patients with cancer-related pain, its use has been extended to chronic noncancer pain.³ Relapse after opioid tapering is not uncommon,⁴ and therefore followup is imperative. Including a 12-month followup after the intervention would help establish the protocol’s sustainability. It is one thing to reduce milligram morphine equivalents (MME), but it is another entirely to reduce MME while maintaining functional status.

When decreasing opioid doses, primary care physicians should advocate for the path of least harm while preserving patient function. This study focused on physician perception of safety but lacked evaluation of patient function and longitudinal followup. All-inclusive care for patients with chronic noncancer pain should incorporate a patient-centered plan that includes functional assessment and long-term followup. It is our responsibility as Family Medicine physicians to care for the whole patient by promoting a sustainable plan to preserve safety and function.