Some patients who have been on long-term opioid therapy may develop a complex form of dependence that may be persistent after opioid discontinuation.
Patient selection: patient receiving opioids
Features:
(1) high daily dose of opioids (>= 100 MME per day) with persistent pain and/or declining function
(2) opioid tapering or discontinuation results in worse pain control and in declining function
(3) there is a protracted abstinence syndrome with clinical deterioration
(4) may have opioid hyperalgesia
(5) may have concurrent psychiatric and/or substance use disorder
One treatment strategy is to start the person on buprenorphine then taper the opioids.
The patient may benefit from referral to a pain specialist.
