Outcomes of Long-Term Opioid Tapering and Buprenorphine Transition

Outcomes in Long-term Opioid Tapering and Buprenorphine
Transition: A Retrospective Clinical Data Analysis
John A. Sturgeon, PhD,* Mark D. Sullivan, MD, PhD,*,†
Simon Parker-Shames, MPH,‡
David Tauben, MD,* and Paul Coelho, MD§
*Department of Anesthesiology and Pain Medicine, University of Washington Medical School, Seattle, Washington; †
Department of Psychiatry and
Behavioral Sciences, University of Washington Medical School, Seattle, Washington; ‡
Synergy Health Consulting, LLC, Ashland, Oregon; §
Department
of Physical Medicine and Rehabilitation/Pain Medicine, Salem Health Pain Clinic, Salem, Oregon, USA
Correspondence to: John Sturgeon, PhD, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine,
4225 Roosevelt Way NE, Seattle WA 98105, USA. Tel: 206-598-4262; Fax: 206-598-4576; E-mail: jasturge@uw.edu.
Disclosure and conflicts of interest: Dr. Coelho acknowledges a grant from the Oregon State Department of Justice. Dr. Sturgeon is a scientific advisory
board consultant for TribeRx. Dr. Sullivan reports grants from Pfizer, personal fees from Revon, personal fees from Aetna, personal fees from Chrono
Therapeutics, and personal fees from the State of Maryland, Attorney General, outside the submitted work. The authors have no other conflicts of inter-
est to disclose.
Abstract
Background. There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently,
there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use.
Methods. The current study details a retrospective review of 240 patients with chronic pain and LTOT presenting for
treatment at a specialty opioid refill clinic. Patients first were initiated on an outpatient taper or, if taper was not toler-
ated, transitioned to buprenorphine. This study analyzes potential predictors of successful tapering, successful
buprenorphine transition, or failure to complete either intervention and the effects of this clinical approach on pain
intensity scores. Results. One hundred seven patients (44.6%) successfully tapered their opioid medications under
the Centers for Disease Control and Prevention guideline target dose (90 mg morphine-equianalgesic dosage), 45
patients (18.8%) were successfully transitioned to buprenorphine, and 88 patients (36.6%) dropped out of treatment:
11 patients during taper, eight during buprenorphine transition, and 69 before initiating either treatment.
Conclusions. Higher initial doses of opioids predicted a higher likelihood of requiring buprenorphine transition, and
a co-occurring benzodiazepine or z-drug prescription predicted a greater likelihood of dropout from both interven-
tions. Patterns of change in pain intensity according to treatment were mixed: among successfully tapered patients,
52.8% reported greater pain and 23.6% reported reduced pain, whereas 41.8% reported increased pain intensity and
48.8% reported decreased pain after buprenorphine transition. Further research is needed on predictors of treatment
retention and dropout, as well as factors that may mitigate elevated pain scores after reduction of opioid dosing.
Key Words: Opioids; Buprenorphine; Chronic Pain; Tapering
Introduction
In the wake of the nationwide opioid crisis, significant
concerns have emerged regarding the use of high-dose
long-term opioid therapy (LTOT) for chronic noncancer
pain. There is limited support for the effectiveness of
LTOT for providing sustained and comprehensive benefit
for individuals with chronic noncancer pain [1–3].
Further, for patients receiving LTOT, there appears to be
a dose-dependent relationship with risk of adverse health
effects [1]. Though rates of opioid prescription have
diminished in recent years, they remain at four times the
level of prescribing in 1999 [4]. Health systems and gov-
ernment agencies have been encouraging tapering of opi-
oid doses or switching to pharmacologic agents with
lower risk profiles in cases where LTOT risks exceed
benefits [5, 6]. However, the quality of evidence is low
regarding the effects of discontinuation or reduction of
high-dose full-agonist opioid use in chronic pain [7, 8].
There is also limited evidence regarding the efficacy of
interventions to reduce LTOT [9]. Two areas of recent
VC 2020 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 1
Pain Medicine, 0(0), 2020, 1–10
doi: 10.1093/pm/pnaa029
Original Research
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empirical inquiry have focused on outpatient opioid ta-
pering protocols [8] and the transition from traditional
full-agonist opioids to buprenorphine [10, 11] to improve
patient safety. Outpatient protocols for opioid taper have
shown some evidence of effectiveness, though the quality
of evidence on this topic remains low overall [8]. At pre-
sent, results are mixed regarding the effects of tapering of
long-term high-dose opioids on pain intensity. Some
studies have reported a mild increase in pain, whereas
others have reported no change or a slight improvement
in pain [12]. Moreover, outpatient tapering protocols
show a significant degree of variability in their approach
and effectiveness and a high degree of patient dropout
for a variety of reasons, including increased pain during
taper [13]. Opioid discontinuation or taper to safer levels
may not be tolerated or appropriate for all patients.
Forced and abrupt tapers have been discouraged by the
Centers for Disease Control and Prevention (CDC) [14].
One study suggested that veterans with psychosis or
post-traumatic stress disorder may develop suicidal idea-
tion in response to opioid taper [15]. Most experts rec-
ommend against opioid discontinuation and abstinence
for patients with moderate to severe OUD [16, 17]. Some
experts have argued that another group of LTOT
patients who do not meet criteria for OUD, but after
years of exposure to opioid therapy are unable to tolerate
opioid taper, may have a condition termed complex per-
sistent opioid dependence; these patients should also not
be completely tapered off opioids [18].
One alternative to opioid taper is transition to bupre-
norphine, a high-affinity partial mu-opioid agonist and
kappa-opioid antagonist. In addition to its ability to re-
duce mortality in patients with OUD, buprenorphine has
shown preliminary efficacy as a substitute analgesic for
patients previously on high-dose full-agonist opioid regi-
mens [10, 11]. As both buprenorphine and opioid taper-
ing protocols may offer ways to reduce the risks of high-
dose full-agonist opioid use, a stepwise approach to opi-
oid reduction may be of value, wherein patients on high-
dose opioids who are unable to tolerate an outpatient ta-
per may benefit from a switch to buprenorphine [6, 11].
The current study details a review of data from 240
patients with chronic pain and high-dose opioid therapy
referred for care to a specialty opioid taper clinic. After
initial evaluation at this clinic, patients were offered an
opportunity for a supported outpatient opioid taper. If
this taper is unsuccessful or tolerated poorly, patients are
given the option of transitioning their opioid regimen to
buprenorphine. In this analysis, we examine the success
rates of each approach and explore potential demo-
graphic and clinical factors (e.g., widespread pain, opioid
dosage, benzodiazepine or nonbenzodiazepine sedative
hypnotic [z-drug] prescription, average pain intensity,
and catastrophic appraisal of pain) as predictors of suc-
cess of outpatient opioid taper or switch to buprenor-
phine for patients who are unable to tolerate a taper of
opioid daily dose to a safer level (90 mg morphine-
equianalgesic dose [MED]).
Methods
The current study is a retrospective chart review of elec-
tronic medical record data from 240 consecutive patients
referred to a specialty opioid refill clinic. The study pro-
tocol was approved by the Institutional Review Board at
Salem Health.
Procedure
The structured opioid refill clinic was opened in October
of 2016 with the development of a formal referral ar-
rangement with the three largest physician groups in
Marion County, Oregon. The opioid refill clinic offers a
significant opioid tapering service (19% of all referrals
are for purposes of opioid taper), consisting of a collabo-
ration between physicians, pharmacists, a nurse practi-
tioner, and medical assistants, and employs opioid
treatment agreements and urine drug testing developed
based on a previously published approach to managing
patients with chronic noncancer pain managed on opioid
therapy in primary care [19]. High-dose LTOT patients,
who provided written consent, were referred in writing
by primary care prescribers for an opioid taper or transi-
tion to buprenorphine at the clinic’s discretion. All refer-
ring providers agreed to consign all opioid management
to the structured opioid refill clinic until the taper was
completed or the patient had been transitioned to bupre-
norphine. These referring providers were encouraged to
obtain their waivers to prescribe buprenorphine under
the Drug Addiction Treatment Act of 2000 (“x-waiver”)
and were advised to prepare to see their patients back
once they were tapered to safer opioid doses or stabilized
on buprenorphine. The majority of patients did ulti-
mately return to care under their referring physician.
At the initial consultation, the purpose of a patient’s
visit (an opioid taper or, if the taper was unsuccessful, a
transition to buprenorphine) was discussed, but no
changes in their opioid regimen were made until the sec-
ond visit. If patients refused to initiate the proposed taper
at the second visit, they returned for care to their refer-
ring primary care providers. If patients were using multi-
ple opioid analgesics, they were permitted to choose
which opioid they wished to taper first. They were
allowed to continue co-prescribed benzodiazepines dur-
ing taper to avoid possibly adding sedative withdrawal
symptoms to opioid withdrawal symptoms. The average
opioid taper rate was 20 MED per month, with pauses in
tapering upon patient request. The taper rate of 20 mg/
mo was established based on clinical observation and on
the clinic’s evaluation of their own patient data. It was
determined that taper rates faster than 20 mg/mo tended
to be accompanied by more frequent complaints of with-
drawal symptoms, increased phone calls to the clinic, or
2 Sturgeon et al.

other indicators of increased patient distress. For patients
300 mg MED, this constituted a pace akin to a taper of
10% per month, which has been used in other tapering
interventions [20].
During the tapering process, care visits involved
follow-up with both the treating physician (PC) and med-
ical assistants trained in assessment of opioid withdrawal
symptoms. Except in rare cases of allergies, all patients
undergoing taper were prescribed 900 mg/d of gabapen-
tin and 2 mg of tizanidine, and other adjuvant medica-
tions were prescribed as needed. Antidepressant
medications were also reviewed and adjusted by the
treating physician as indicated. Patients were offered the
option of sublingual buprenorphine if they failed opioid
taper by demonstrating persistent withdrawal symptoms
(hyperkatifeia) or aberrant behaviors (e.g., exceeding
daily prescribed opioid doses or requiring early refills).
The transition process to buprenorphine was catego-
rized as either “urgent” or “nonurgent.” Urgent transi-
tions were designated when there was evidence of
aberrant behaviors, such as running out of medications
early on a repeated basis or inconsistencies on urine drug
testing. In urgent transition, patients underwent a with-
drawal period of 24 hours for all opioids (except for fen-
tanyl patches or methadone, where 48-hour withdrawal
periods were utilized instead) while being prescribed
2 mg of tizanidine, an a-2 agonist, three times per day for
the management of medically supervised withdrawal
symptoms. After this withdrawal period, patients under-
went buprenorphine transition in the office. Prescribing
gabapentin for urgent transitions was not possible due to
the urgent and condensed timeline of transition off of
full-agonist opioid medications.
For nonurgent transitions, patients were scheduled for
an appointment one month in advance to plan the transi-
tion and explain the process of buprenorphine initiation,
including the risk of precipitated withdrawal. Patients
were asked to bring their full-agonist opioids for a pill
count and to dispose of any extra medications using
onsite disposal. Medical assistants calculated the transi-
tion date based on the number of remaining pills for each
patient and provided a calendar based on this schedule
for each patient. During this appointment, patients were
provided prescriptions for gabapentin up to 900 mg/d
over the ensuing month leading up to the transition date,
tizanidine 2 mg three times a day (TID) on the day of
withdrawal, and then scheduled for transition on the day
following the end of their remaining full-agonist opioids.
During the appointment, it was explained to patients that
precipitated withdrawal was possible if they did not ad-
here to the abstinence period that was delineated. For
patients who reported a high degree of anxiety related to
withdrawal symptoms, quetiapine 50 mg TID was also
initiated during the 24–48-hour withdrawal period in
some cases (5–10% of patients in the overall sample).
Patient data were extracted from the clinic’s electronic
medical record (EMR) regarding morphine-equianalgesic
opioid dose, pain intensity, and demographic and medi-
cal data. Adverse outcomes, including patient suicide and
emergency department visits, were also monitored via the
clinic’s EMR and via the state’s emergency department
information exchange (EDIE).
For this study, patients were categorized according to
three potential outcomes of opioid taper: 1) successful
completion of a taper 90 mg MED, 2) transition to
buprenorphine from full-mu-agonist opioids, or 3) failure
of taper without initiation of buprenorphine, failure of
both taper and buprenorphine transition, or loss to fol-
low-up after initial consultation. Patient scores on ques-
tionnaires and medication dose were extracted at two
time points for each patient: at their initial consult and at
a time point at least one month after completion of their
intervention (i.e., one month after completion of the out-
patient taper or buprenorphine transition).
Participants
Data were included only for patients with initial full-ago-
nist opioid doses above the CDC-recommended dose of
90 mg MED (801 total patients were reviewed, with 240
meeting this criterion). The patient flow diagram can be
seen in Figure 1, and a description of patient characteris-
tics is included in the Results section.
Measures
Opioid Dose
Opioid daily dose was computed as a morphine-
equianalgesic dosage (MED) using mean dosage over the
previous month using the Oregon State calculator
(https://www.oregonpainguidance.org/opioidmedcalcula
tor/). Buprenorphine conversion from other opioid MED
was based on the CDC’s published equivalents for sublin-
gual buprenorphine [21].
Pain Intensity
Average pain intensity was assessed using an 11-point
numeric rating scale (NRS), from 0 (no pain) to 10 (worst
pain). The NRS for pain intensity has been validated for
use in chronic pain populations [22].
Pain Catastrophizing
Pain catastrophizing was assessed at time of referral us-
ing the Pain Catastrophizing Scale (PCS) [23]. The PCS
identifies an inability to disengage from thoughts about
pain, magnification of the negative consequences of pain,
and helplessness regarding one’s ability to cope with pain
and its negative effects [23]. Greater scores on the PCS
have also been associated with patterns of prolonged opi-
oid use in chronic pain [24] and postsurgical populations
[25]. The PCS consists of 13 items, scaled from 0 (“not at
all”) to 4 (“all the time”), and scores are computed as a
sum score ranging from 0 to 52.
Opioid Tapering and Buprenorphine Transition Outcomes 3

Widespread Pain
The degree of widespread pain was assessed using the
Fibromyalgia Survey Questionnaire (FSQ) [26]. This as-
sessment is based on the 2016 American College of
Rheumatology criteria for diagnosis of fibromyalgia and
utilizes an index of widespread pain in joints and body
parts, as well as other symptoms (headache, cognitive
complaints, depression, unrefreshing sleep, fatigue, and
abdominal pain). FSQ scores range from 0 to 31 and are
computed as a summation of a somatic symptom severity
score (ranging from 0 to 12) and a widespread pain index
(ranging from 0 to 19). The FSQ has been used in mixed
chronic pain samples [27, 28] and has been used as both
a diagnostic cutoff [27] and as a continuous measure
across different diagnostic groups with chronic pain [28].
The FSQ has also been associated with an increased like-
lihood of prolonged opioid use in prior research, primar-
ily in postsurgical populations [29, 30].
Analytic Plan
All analyses were conducted using SPSS, version 25.0
(IBM Corp, Armonk, NY, USA). Given the nonrandom-
ized but structured clinical approach being tested, analy-
ses focused on success rates and prognostic indicators of
patients’ success with opioid tapering 90 mg MED or
successful transition to buprenorphine. Group differences
in key clinical variables (MED, pain intensity, PCS, FSQ,
and presence of a benzodiazepine/z-drug prescription)
and demographic factors (age, gender) were computed
between treatment using a three-group categorization
(“successful taper 90 mg MED,” “successful buprenor-
phine transition, and “treatment dropout”). The dropout
group was comprised of patients who initiated but did
not complete an outpatient taper but who continued care
with the clinic and provided follow-up data. Chi-square
tests were used to evaluate group differences in categori-
cal variables. Given that we noted a significant degree of
skewness and kurtosis in MED variables, nonparametric
Kruskal-Wallis independent-samples tests were used to
test differences in continuous variables across treatment
groups. For any variable for which there was a significant
omnibus difference, nonparametric Mann-Whitney U
tests were used to compare pairwise differences between
groups.
Comparisons between median pain intensity scores at
initial visit and follow-up between the successful taper
and buprenorphine group were estimated using related-
samples Wilcoxon signed rank tests. Patients in the drop-
out group had a very high rate of data attrition (81.8%
of patients in this group did not have available follow-up
data) and were thus excluded from these analyses.
Correlations between change in MED and pain intensity
scores from the initial clinic visit to the later follow-up
time point were computed both as an omnibus correla-
tion and between groups that successfully returned for
follow-up. Given the non-normality of MED variables,
Kendall’s tau [31] was used to estimate these
correlations.
Results
Demographic characteristics of the sample can be found
in Table 1, and descriptive statistics for each intervention
group can be found in Table 2. Regarding the frequency
of responders to each intervention, 107 patients (44.6%
of the overall sample) successfully completed a taper to a
MED 90 mg, 45 patients (18.8%) who failed taper to
90 mg MED were successfully transitioned to
IniƟal Consult (n=801)
IniƟated Taper (n=171)
Drop out before iniƟaƟon (n=69)
Taper
Buprenorphine InducƟon (n=53)
Successful taper (n=107)
Drop out aŌer iniƟaƟon (n=11)
Successful buprenorphine (n=45)
Drop out during/aŌer inducƟon (n=8)
Enrollment
Total drop out
aŌer inclusion
(n=87)
12-Week
Follow-up
Included, MED90 (n=240)
Excluded, MED=90 (n=561)
Figure 1. Patient ﬂow diagram.
4 Sturgeon et al.

buprenorphine and maintained on this medication at one
month, 11 patients (4.6%) dropped out of the taper pro-
tocol without initiating buprenorphine transition, eight
patients (3.3%) dropped out of buprenorphine transition
after failing an initial taper, and 69 patients (28.7%)
failed to follow-up after initial consultation. The mean
duration of time between the initial consult and the date
of follow-up assessment (which occurred at least one
month after completion of taper or buprenorphine transi-
tion) (SD), range) was 8.24 (5.30, 1.6–27.1) months.
Review of EMR and EDIE data indicated that there were
no patient suicides in the patient sample, nor was there
evidence of initiation of illicit drug use, which was con-
firmed by sequential urine drug screening during the
treatment period. The median daily opioid dose at initial
consult for the overall sample (IQR, range) was 182
(135–270, 100–3,200) mg MED. At initial consult, 65
patients (27.1% of the sample) had a concurrent pre-
scription for a benzodiazepine or z-drug. The average
pain intensity at initial consult (SD, range) was 6.03 out
of 10 (1.65, –10).
All variables were normally distributed except for
MED values at the initial visit (skewness ¼ 7.84, kurtosis
¼ 83.6) and MED values at the follow-up visit (skewness
¼ 3.59, kurtosis ¼ 16.7). Among patients who success-
fully tapered, the mean duration of outpatient taper (SD,
range) was 4.49 (3.17, 1–14) months. The distribution of
changes in MED and pain intensity scores from baseline
to follow-up comparing successful tapering, successful
buprenorphine transition, and treatment dropout groups
can be found in Figure 2, and the distributions of these
groups are represented separately in Figure 3. There was
a marginally significant association between changes in
opioid dose MED and changes in pain intensity (s(148) ¼
–0.107, P ¼ 0.073); when tested separately between
treatment groups, this association was not significant in
either the buprenorphine transition group (s(43) ¼ –
0.186, P ¼ 0.099) or the successful taper group (s(89) ¼
–0.088, P ¼ 0.26).
Among the 89 patients who successfully tapered their
opioid dose 90 mg MED and had available pain inten-
sity data at initial visit and at one month after taper ces-
sation, 47 (52.8% of the group) reported a higher pain
intensity at the point of taper cessation, 21 (23.6%)
reported no change in pain, and 21 (23.6%) reported an
improvement in pain intensity. Thirty-three patients in
this successfully tapered group (37.1% of the group)
reported an increase in pain intensity of two points or
more from baseline to the cessation of taper. Among
patients successfully tapered to 90 mg MED, the me-
dian pain intensity increased by 0.72 out of 10 during
the period between baseline and one month after taper
cessation, which was statistically significant (Z ¼ 2.83, P
¼ 0.005).
Among the 43 patients who successfully transitioned
to buprenorphine after failing a taper attempt (with
available pain intensity scores at the initial visit and at
one month after buprenorphine transition), 18 patients
(41.8% of the sample) reported greater pain intensity at
follow-up, four patients (9.3%) reported no change in
pain intensity, and 21 patients (48.8%) reported an im-
provement in pain symptoms. Of the patients reporting a
pain increase after transition to buprenorphine, 13
patients in this group (30.2% of the buprenorphine
group) reported an increase in pain intensity of two
points or more. There was not a significant difference in
median pain intensity from baseline to follow-up among
patients successfully transitioned to buprenorphine (Z ¼
–0.442, P ¼ 0.66).
When group differences in clinical and demographic
characteristics were compared between patients who suc-
cessfully tapered, those who successfully transitioned to
buprenorphine, and those who did not complete either
treatment arm, a significant difference was noted in ini-
tial opioid dose (H ¼ 22.1, P 0.001). Patients who suc-
cessfully transitioned to buprenorphine (median ¼ 265)
had significantly higher initial opioid doses compared
with patients with successful taper (median ¼ 172.5,
U ¼ 1175, P 0.001) and dropout groups (median ¼
180, U ¼ 1291, P ¼ 0.003). The dropout group also
showed a significantly higher initial opioid dose com-
pared with the successful taper group (U ¼ 3838, P ¼
0.033). There was also a significant difference in benzo-
diazepine prescription status (omnibus v2
(2) ¼ 7.98, P ¼
0.018); group-wise comparisons indicated a significantly
Table 1. Demographic characteristics of patient sample
(N ¼ 240)
Demographics No. (%) or Mean (SD, Range)
Age, y 57.8 (10.9, 25–93)
Race 230 (95) self-identiﬁed as white
Sex 56.7% female
Work status
Disabled 144 (60)
Retired 39 (16.5)
Working 37 (15.4)
Homemaker 16 (6.7)
Payer
Medicare 128 (53.5)
Commercial 62 (25.8)
Medicaid 43 (17.9)
Other 4 (1.7)
Median education Some college without a degree
Medical diagnoses
Chronic low back pain 143 (59.6)
Fibromyalgia 19* (7.9)
Abdominal pain 12 (5)
Back and sciatic pain 11(4.6)
Joint pain 10 (4.2)
Rheumatoid arthritis 5 (2.1)
Mental health diagnoses
Depression 188 (78.3)
Anxiety disorder 154 (64.2)
PTSD 37 (15.4)
*Fifty-four percent met 2016 American College of Rheumatology criteria
for ﬁbromyalgia [31].

higher rate of benzodiazepine prescription in the dropout
group (N ¼ 33, 37.5%) than in the successful taper group
(N ¼ 24, 22.4%, v2
(1) ¼ 5.30, P ¼ 0.021) or in patients
successfully transitioned to buprenorphine (N ¼ 8,
17.7%, v2
(1) ¼ 5.43, P ¼ 0.020). No differences were
noted in terms of age, gender, baseline, or follow-up pain
intensity, or FSQ scores between treatment arms.
Discussion
The current study describes a retrospective review of out-
comes for 240 consecutive patients on high-dose full-mu-
agonist opioid medications referred to a specialty opioid
refill clinic. Of these patients, 44.6% successfully transi-
tioned to a MED 90 mg and 18.8% failed taper but
were successfully transitioned to buprenorphine. The av-
erage opioid taper rate was 20 MED per month, and all
patients were permitted to pause the taper upon request.
The current study is among the first to describe a step-
wise clinical approach to the management of high-dose
opioids: a paced outpatient opioid taper followed, if nec-
essary, by a transition to buprenorphine.
We observed a significantly higher baseline opioid
dose among patients who failed opioid taper and were ul-
timately transitioned to buprenorphine compared with
those who successfully completed an opioid taper to a
daily dose 90 mg MED or failed to complete either
treatment. Group comparisons suggested that those
patients on relatively higher doses of opioids appeared
more likely to fail an initial taper and to successfully be
transitioned onto buprenorphine. To our knowledge, this
result extends prior findings in the opioid and chronic
pain literature, though prior studies indicate decreased
benefit from buprenorphine for patients at MEDs
400 mg [11] and an increased risk of discontinuation of
outpatient taper for patients at MEDs 100 mg [32]. A
benzodiazepine or z-drug prescription at initial visit was
seen in a significantly larger proportion of patients who
ultimately failed or dropped out of taper or buprenor-
phine transition, compared with patients who ultimately
completed an outpatient taper or buprenorphine transi-
tion. This finding is notable, as co-prescribing of benzo-
diazepines or z-drugs with opioids is common for
individuals with chronic pain and is known to increase
Table 2. Descriptive statistics
Successful Taper (N ¼ 107) Buprenorphine (N ¼ 45) Dropout (N ¼ 88)
Initial MED, median (IQR, No.) 180 (120–240, 107) 265 (180–375, 43) 180 (140–284.5, 88)
Follow-up MED, median (IQR, No.) 90 (60–90, 106) 120 (90–240, 43) –
Initial pain intensity, median (IQR, No.) 6.00 (1.60, 107) 5.93 (1.86, 45) 6.11 (1.62, 82)
Follow-up pain intensity, mean (SD, No.) 6.64 (1.93, 89) 5.58 (2.36, 43) –
PCS, mean (SD, No.) 21.10 (13.4, 105) 24.05 (15.1, 43) 19.65 (14.0, 88)
FSQ, mean (SD, No.) 14.68 (5.81, 93) 13.22 (6.25, 37) 14.75 (5.53, 81)
Buprenorphine MED estimates based on the Centers for Disease Control and Prevention’s published conversion factors [20].
FSQ ¼ Fibromyalgia Symptom Questionnaire; IQR ¼ interquartile range (25th to 75th); PCS ¼ Pain Catastrophizing Scale.
Figure 2. Distribution of change scores in pain intensity across proportions of MED reduction. Blue line reﬂects line of ﬁt for all in-
cluded data.
6 Sturgeon et al.

opioid overdose risk [33]. This finding is consistent with
evidence that benzodiazepine use is a predictor of persis-
tent opioid use after surgery [34, 35].
A key question in the current study was the effect of
tapering or transition to buprenorphine on pain intensity.
In this regard, our results were mixed. Among patients
who successfully tapered 90 mg MED, there was a sta-
tistically significant increase in median pain intensity
from baseline to follow-up. In contrast, patients who
were successfully transitioned to buprenorphine did not
show a significant change in median pain intensity from
baseline to follow-up. Approximately one-third of
patients (37.1% of the taper group and 30.2% of the
buprenorphine group) did report an elevation in pain
symptoms of at least 2/10 points at follow-up. However,
there was a considerable proportion of patients in both
the successful taper and buprenorphine groups that
reported either no change in pain (23.6% for successfully
tapered patients and 9.3% for patients transitioned onto
buprenorphine) or an improvement in pain symptoms
(23.6% of patients in the taper group and 48.8% of
patients transitioned onto buprenorphine) after comple-
tion of the interventions. Contrary to the fears of many
patients receiving LTOT, these findings indicate that ta-
pering and buprenorphine transition may have negligible
or beneficial effects on the severity of pain for many
patients. However, more rigorously controlled interven-
tion studies are needed to more fully support this
conclusion.
Prior studies of opioid tapering have not suggested a
consistent or robust relationship between opioid tapering
and pain intensity [8]. Our findings identified relatively
few baseline demographic or clinical characteristics that
predicted success of opioid taper or buprenorphine tran-
sition, so there remains a need to understand the hetero-
geneity in patient responses to these interventions.
Despite this limitation, however, our findings suggest
that a flexible clinical approach, emphasizing first a
structured outpatient taper and a transition to buprenor-
phine for failed tapers, may be a viable treatment ap-
proach to improving treatment safety and possibly
patient outcomes in individuals with concurrent chronic
pain and high-dose LTOT.
We believe that patient-centered characteristics of
these tapers, consisting of allowing patients to control
the order in which pharmacologic agents were tapered
and pausing the tapers when needed, helped increase pa-
tient participation and toleration of the tapering process.
Underscoring this, we observed no adverse outcomes
such as suicides or transitions to illicit opioids among the
entire cohort. Moreover, we believe that tapering high-
dose LTOT patients can have derivative benefits for both
patients’ immediate family and the community at large
by reducing the reservoir of risky medication in the com-
munity [36]. Our combined taper and buprenorphine
transition resulted in a community-wide reduction in
schedule II opioids of 28.5 kg over the 30 months of this
study.
Figure 3. Distribution by group of change scores in pain intensity across proportions of MED reduction. Line of ﬁt represents data
in each treatment group separately.

Limitations
There are some limitations that should be noted in inter-
preting the current study findings. First, the current study
sample is comprised of patients who were referred and
ultimately chose to present for treatment at an opioid re-
fill clinic with a significant de-prescribing practice. We
believe that these patients are likely typical of higher-
dose LTOT patients in other practices, but we cannot
demonstrate this. We are not able to account for those
patients who chose not to attend the clinic or were un-
able to do so due to other barriers (e.g., insurance, geog-
raphy). Follow-up data are missing on patients who
dropped out of care. Replication of our findings in ran-
domized clinical trials is necessary to verify the validity
of these effects. The generalizability of our findings is
also unclear. Our patient sample is comprised of a very
high proportion of patients who were not working:
80% of the sample was on disability, retired, or not
working for other reasons. Other studies have also found
high rates of disability among high-dose LTOT patients
[37]. However, we cannot state whether a similar pattern
of findings might have emerged in a sample comprised
primarily of patients who maintained consistent or full-
time work. Our ability to characterize the current patient
population was limited to the presence of a few self-
report measures and information that could be extracted
from electronic medical records (e.g., mental health diag-
noses, demographic diagnoses). Many other indicators
(e.g., socioeconomic factors, current physical or psycho-
social function, disability and lawsuit status, social sup-
port, sleep disturbance, ongoing life stress, or other
medical comorbidities) may play a role in the success or
failure of opioid de-prescription. We only used mental
health diagnoses in the electronic health record and were
unable to articulate current levels of psychiatric symp-
toms (e.g., depressive symptoms), which have been iden-
tified as a potential barrier of effective opioid tapering
[38]. Opioid withdrawal symptoms were also not
assessed in the current patient sample. Opioid with-
drawal can occur even during slow and supervised opioid
tapering and may include uncomfortable physical and
psychological symptoms [14].
Future Directions
There are several avenues by which future research could
better delineate the effectiveness of this approach to re-
ducing risk for patients on high-dose LTOT. There is evi-
dence that opioid tapering outcomes may be bolstered by
engagement with self-management or psychological
approaches at the time of opioid taper [39]. We also wish
to acknowledge the difficulty inherent in initiating full-
agonist opioid tapers in patients who have been on these
medications for a long time. Indeed, prior research has
highlighted that many prescribing providers experience a
significant barrier in terms of introducing tapering as a
clinical approach due to limited support, resources, or
time, or feel that these interventions may adversely affect
treatment alliance or contribute to greater clinician bur-
den and ultimately burnout [40, 41]. Further, a recent
retrospective study of data from a large academic health
care system in an urban setting noted an increase likeli-
hood of treatment dropout among patients who were ini-
tiated on a full-agonist opioid taper compared with those
who received continuation of their full-agonist opioid
regimens over a calendar year [42]. These findings sug-
gest that tapering approaches may not be immediately
suitable for all patients, nor will all providers feel ade-
quately prepared to initiate tapers effectively.
Consequently, we urge further inquiry into factors that
contribute to patient readiness to taper, as well as
approaches that help to prepare front-line clinical pro-
viders for more effective implementation of tapering and
safe prescribing patterns. Similarly, other medications
known to treat pain, withdrawal symptoms, or psychiat-
ric distress (gabapentin, tizanidine, and quetiapine) were
routinely utilized to support opioid tapering or transition
to buprenorphine and may have played a role in patient
responses to either intervention. However, the frequency
and duration of use were not well articulated in the exist-
ing data set, and as a result, delineating the specific
effects of these medications on patient responses to taper-
ing or buprenorphine transition may be valuable in fu-
ture studies. There is also a need to extend the current
findings in more diverse populations: The vast majority
of the sample was Caucasian. There is limited evidence
for how a similar treatment approach may function in
minority populations. This inquiry is important given ev-
idence of differential pain management among individu-
als of racial and ethnic minority groups [43, 44] and the
consequences that this may have for patients’ alliance
with their treatment providers [45]. It would also be of
value to articulate the role of opioid withdrawal symp-
toms, such as anhedonia or craving symptoms, in
patients’ willingness and ability to complete a reduction
or transition in their medication regimen [46, 47]. In ad-
dition, the relatively large proportion of patients transi-
tioned to buprenorphine who reported either no change
or a reduction in their pain symptoms suggests that it
may be valuable for future studies to examine the suit-
ability of buprenorphine transition in LTOT as a suitable
standalone intervention, particularly for patients who
may be unable or unwilling to initiate an outpatient
taper.
Conclusions
The current study presents data from 240 patients with
chronic pain and concurrent high-dose full-agonist opi-
oid use referred to a specialty opioid refill clinic for re-
duction of high-dose opioid prescription. Patients who
returned for follow-up underwent an outpatient taper. If
this taper was not tolerated, a transition to buprenor-
phine was initiated. Approximately 63% of patients in
8 Sturgeon et al.

the current sample were able to complete either an opioid
taper to a daily dose 90 mg MED or a transition to
buprenorphine. Results suggested no significant associa-
tion between reductions in MED and increases in pain in-
tensity, and there was significant variability in response
to both interventions: 53% of successfully tapered
patients and 42% of those transitioned onto buprenor-
phine reported elevated pain, compared with 24% of
tapered patients and 49% of patients transitioned to
buprenorphine reporting improved pain at least one
month after completion of the intervention. Our findings
indicate that a structured, tiered approach to high-dose
opioid management may allow patients to transition to
lower, safer doses of opioids that are consistent with re-
cent CDC guidelines. Future studies may benefit from
replication of these findings in more demographically
and socioeconomically diverse populations, assessment
of withdrawal symptoms and psychosocial factors that
may affect tolerability of these interventions, and assess-
ment of pharmacological adjuvants and supportive and
self-management-focused interventions that may improve
tolerability and adherence to opioid de-prescribing.
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