(213) Opioid exit plans: A systematic review on tapering strategies upon hospital discharge for non-cancer pain

Background: In response to the opioid crisis, discharge counselling can be extended to include opioid exit plans (OEPs). These transitional services aim to minimize the risk of a patient developing opioid dependency following hospitalization. Currently, there is no standard OEP approach in tertiary care.

Objectives: To conduct a systematic review to summarize the interventional elements and evaluate the efficacy of published OEPs.

Methods: PubMed and Embase are systematically searched to identify published OEPs in a postoperative patient population between January 1, 2000 and June 4, 2024. Two researchers independently screened articles for eligibility following the PRISMA 2020 guidelines. Study quality and bias were assessed following the LEGEND evidence evaluation system and the Cochrane risks of bias tools. Variables were extracted concerning the categories: general information, methods, population and setting, intervention, participants, intervention groups, outcomes, results, applicability, and other information. Data synthesis was performed for study characteristics, intervention details, efficacy, and development.

Results: A total of 2,585 articles were screened, with eight meeting the eligibility criteria. Three studies were of good quality, and none had a low risk of bias. All studies were conducted in North America (USA or Canada) and focused on orthopedic surgery patients following total hip or knee arthroplasty (n=5) or neurosurgery (n=3). Most studies (n=7) included a pre-post (n=4) or randomized clinical design (n=3). The interventions varied and ranged from educational sessions (n=1) to individualized tapering protocols (n=4), or a combination of the two (n=2). Key elements were instructions on how to anticipate patients’ postoperative need for opioid analgesics and tapering strategies based on the 24-hour pre-discharge opioid consumption. Of the published OEPs, the most common element was an individualized tapering plan that was based on pre-discharge opioid consumption among orthopedic surgery patients. Six studies included efficacy as an endpoint in their analysis, of which four assessed statistical significance with all four identifying that the OEPs were successful in reducing post-surgery opioid use.

Conclusions: Despite differences in the patient populations, the studies that evaluated efficacy found that OEPs with tapering plans reduced opioid consumption by 56 to 67% after six weeks compared to usual care groups. More rigorous studies are needed to assess the efficacy of these tapering approaches on a larger scale.