Rationales for abrupt discontinuation of long-term opioid therapy for chronic pain: A thematic analysis

Evidence and clinical guidelines document serious negative health consequences of abrupt discontinuation of long-term opioid therapy (LTOT). Nevertheless, recent studies suggest that up to 80 percent of patients with chronic pain who undergo LTOT deprescribing have their prescriptions abruptly discontinued. Given the frequency and high-risk nature of this practice, it is critical to understand the decision-making processes of physicians implementing abrupt opioid discontinuations while treating patients with chronic pain prescribed LTOT.

In the present study, physicians were instructed to imagine working in a primary care setting and taking over the care of patients with chronic pain on LTOT. Physicians were presented with 12 simulated patient vignettes. Physicians indicated how they would manage patients' existing opioid prescription and then described their rationale for these decisions.

One hundred physicians participated and completed 1,200 encounters with simulated patients. This study presents thematic analysis of treatment rationales for encounters in which physicians indicated their intention to abruptly discontinue LTOT. Nearly half of physicians (47 percent) immediately discontinued LTOT in at least one patient encounter. An iterative, thematic approach was used to analyze physicians' rationales. The following themes emerged from physician rationales for this action: (1) a preference for first-line treatments for chronic pain, (2) concerns around risk of adverse health consequences, (3) absent or inadequate opioid-related benefit, and (4) a consideration of active pain management strategies.

Although physicians frequently considered guideline-relevant -factors-opioid safety risks, potential misuse, and functioning-they often arrived at a guideline-discordant treatment decision, namely abrupt discontinuation.