RESUMEN
Background: Pain management physicians are increasingly focused on limiting prescription opioid abuse, yet existing tools for monitoring adherence have limited accuracy. Medication event monitoring system (MEMS) is an emerging technology for tracking medication usage in real-time but has not been tested in chronic pain patients on long-term opioid regimens. Objective: We conducted a pilot clinical trial to investigate the utility of MEMS for monitoring opioid adherence and compared to traditional methods including self-report diaries, urine drug screen (UDS), and physicians' opinions. Methods: Opioid-maintained chronic pain patients were recruited from a pain management clinic. Participants (n=28) were randomly assigned to either receive MEMS bottles containing their opioid medication for a 90-day period or to continue using standard medication bottles. MEMS bottles were configured to record and timestamp all bottle openings and the number of pills that were removed from the bottle (via measurement of weight change). Results: Participants who received MEMS demonstrated highly heterogenous dosing patterns, with a substantial number of patients rapidly removing excessive amounts of medication and/or "stockpiling" medication. By comparison, physicians rated all participants as either "totally compliant" or "mostly compliant". UDS results did not reveal any illicit drug use, but 25% of participants (n=7) tested negative for their prescribed opioid metabolite. MEMS data did not correlate with physician-rated adherence (P=0.24) and UDS results (P=0.77). MEMS data consistently revealed greater non-adherence than self-report data (P<0.001). Conclusion: These results highlight the limits in our understanding of naturalistic patterns of daily opioid use in chronic pain patients as well as support the use of MEMS for detecting potential misuse as compared to routine adherence monitoring methods. Future research directions include the need to determine how MEMS could be used to improve patient outcomes, minimize harm, and aid in clinical decision-making. Trial Registration: This study was preregistered on ClinicalTrials.gov (NCT03752411).
RESUMEN
INTRODUCTION: The opioid epidemic and current opioid use guidelines for chronic noncancer pain have resulted in an overwhelmingly large number of patients undergoing opioid tapers. Even though the literature for tapering guidelines is growing, there is little guidance for tapering patients on ultra high-dose opioids. CASE DESCRIPTION: This case report describes in detail the opioid tapering approach used to taper a 53-year-old male with chronic low back pain on a regimen of a morphine equivalent daily dose (MEDD) of 1,990 mg. Patient reported many side effects such as chronic nausea, irritability, psychomotor depression, and functional impairment. He was admitted for a medically supervised opioid taper for 12 days. RESULTS: The patient was discharged with an MEDD of 392 mg with additional taper as an outpatient to an MEDD of 200 mg. Adequate pain relief and resolution of side effects were achieved without the patient reporting significant withdrawal symptomatology in the outpatient setting.
