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Comment & Response
June 2018

Voluntary Opioid Tapering—Barriers to Delivering Care

Author Affiliations
  • 1Boston PainCare Center, Waltham, Massachusetts
  • 2Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
  • 3Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts
  • 4Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. 2018;178(6):874-875. doi:10.1001/jamainternmed.2018.2115

To the Editor We commend Dr Darnall and her colleagues for their recent investigation of voluntary opioid tapering.1 Although the authors provided a novel model for care, we believe that there exists considerable ground that still needs to be broken.

It is particularly concerning that the study completers and dropouts started on extremely high doses of opioids, and end-of-study doses were well above those recommended in the recent CDC opioid prescribing guidelines.2 Although an overview of Cochrane Reviews3 concludes that “no evidence-based argument can be made on the use of high-dose opioids, ie 200 mg morphine equivalent or more daily, in clinical practice,” adverse events still would be expected at levels in the posttaper 150 mg morphine equivalent daily dose (MEDD) range. The recent study by Darnall et al4 questions the degree to which its results can be extrapolated to primary care, where most chronic pain is treated and the fear of regulatory sanction provides an added barrier. Even a low dose of opioids can be daunting for the primary care physician, for example Indiana’s “trigger” dose of 15 mg MEDD for more than 3 months, which is considerably lower than the CDC recommendations.

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