For the past several decades, opioids have been the mainstay for treating patients with
chronic pain. In recent years it has become apparent that there are significant harms and
limited benefits to opioid medications for the long-term management of chronic pain, and
guidelines recommend that opioids are de-prescribed for patients with chronic pain.

Patients may be reluctant to engage with opioid tapering advice for a number of reasons, including

• patients’ belief that the risk of accidental overdose doesn’t apply to them
• the difficulty of prioritising the prevention of uncertain future harms over certain pain-related distress in the present
• pessimism about the value of non-opioid options for pain management
• attributing opioid tapering advice to clinician mistrust and suspicion of drug
  dependence or drug misuse.

The most proximal challenge to engaging patients with opioid-tapering advice, however, is patient emotion.  Negative emotions such as fear, anxiety, worry, irritation, anger, or shame are almost inevitable responses to opioid tapering advice. Patients may be anxious about increased pain or withdrawal symptoms, may be ashamed of their chemical dependence on prescribed medications, and may express anger towards the clinician who has been responsible for their prescribing over the years. Even patients who are, in principal, positive and enthusiastic about the prospect of living opioid-free can at the same time feel a degree of anxiety or worry about the prospect of change in their pain management strategy (Ashton-James et al., 2019).

Patients’ emotional responses to opioid tapering advice are understandable and need to be managed because they have the potential to derail patient engagement. Anger reduces our propensity to trust others and acceptance their advice; fear and anxiety increase perceptions of risk and reduce willingness to take risks; shame undermines self-efficacy and in turn poses a significant challenge to behaviour change. On the other hand, feelings of authentic pride, happiness, and gratitude increase self-confidence, promote behaviour change, increase propensity to trust others, and consequently, increase willingness to accept and adhere to advice from others.

Dr Ashton-James works with clinicians from all disciplines and specialties to provide them with evidence-based communication strategies for optimising patient engagement with and acceptance of opioid tapering advice. In part, this involves teaching clinicians how to defuse patients’ negative emotions and create opportunities for patients to experience more positive emotion during conversations about opioid tapering.

To learn more, please get in touch.