Special Topics in Pain: Opioids

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Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial.

Author(s): Sullivan, et al.
Journal: The Journal of Pain. 2017; 18(3):308-318. 33 references.
Reprint: Mark D. Sullivan, MD, PhD, University of Washington, Box 356560, Seattle, WA 98195. E-mail: sullimar@uw.edu
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose. Please see original article for disclosures.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids

Editor’s Note:  Tapering opioids is oftentimes met with resistance from many patients.  This study looks at an opioid tapering support protocol to help patients wean from opioids, which included psychiatric consultation, opioid dose tapering, and 17 meetings with a physician assistance for motivation and CBT interventions.  Not surprisingly, there was a trend towards greater tapering with less psychosocial problems with the protocol.  However, the study itself was underpowered, and most of the endpoints did not reach significance with 18 patients in the protocol arm and 17 patients in the normal treatment arm.  With additional evidence in this area showing improvement, we can hope that this eventually becomes more standard of care with increased access and greater approval by payors. 

Opioid tapering after years of therapy may be difficult for the patient and is feared by many patients. It is possible that opioid taper may be accomplished without significant worsening of pain, mood, and function, according to data concerning opioid taper within multidisciplinary pain rehabilitation programs. However, no protocol for taper of long-term opioid therapy (LtOT) among outpatients treated for chronic pain has been tested.

This nonblinded RCT was conducted at a pain center at a large university medical center in Seattle, Washington from May 2013 to September 2015. Study participants were recruited through clinician referrals and clinic advertisements at the pain center and via referrals from other medicine specialty, primary care clinics at the medical center and other pain clinics in the Seattle area. Patients were screened, enrolled, and baseline assessments for pain, anxiety, insomnia, pain self-efficacy, patient health, and opioid craving were administered by the research staff. Patients were than randomized into the taper support group (n= 18) and the usual care group (n= 17).

The taper support intervention protocol included psychiatric consultation, opioid dose tapering and 17 weekly meetings with a physician assistant to explore motivation for tapering and learn cognitive-behavioral therapy (CBT) interventions for pain, as well as education and training in relaxation techniques, behavioral goal-setting, sleep hygiene, and maintaining gains and coping with pain flare-ups.

Patients randomized to usual care received care for their pain, including opioid prescriptions from their usual prescribers, as they would as if they were not in the study, with no restrictions other than avoiding buprenorphine for the duration of the study.

The primary outcome was mean daily opioid dose at 22 weeks after randomization. Secondary outcomes were opioid dose at 34 weeks after randomization and percent reduction (from baseline) in opioid dose at 22 and 34 weeks. Assessment measures were administered at 22 and 34 weeks.

The primary outcome, a mean daily morphine equivalency dose (MED) from baseline, was 43 mg lower in the taper group than that of patients randomized to usual care, although this difference was not statistically significant. The taper support group achieved more than double the percent reduction in MED achieved in the usual care group (43% vs 19%). The differences observed between groups in our study are clinically meaningful.

It is of note that patients in the taper support group, compared to those in usual care, had lower pain interference scores at 22 and 34 weeks. Furthermore, those in the taper support group had significantly higher self-efficacy for managing pain and significantly lower levels of perceived opioid-related psychosocial problems (loss of interest in usual activities, trouble concentrating, feeling down or sluggish) at 22 weeks. These findings suggest that training in CBT-base pain self-management skills is effective in decreasing pain interference with activities and in increasing patients' confidence that they can manage their pain.

It is important to note that the opioid dose reduction in the taper support and usual care groups was achieved without a significant increase in pain severity. In fact, pain severity decreased on average from baseline to 22 weeks by approximately 1 point on the 0 to 10 scale in the taper support group and approximately a half point in the usual care group.

Patients in the opioid taper support group, compared with patients in the usual care group, did not differ in levels of reported opioid misuse, depressive symptoms, or opioid control concerns at 22 and 34 weeks. Patient health and anxiety assessments also did not differ significantly between the taper support and usual care groups at either follow-up. However, adjusted mean differences between groups consistently favored the taper support group over usual care on measures of insomnia, somatic symptom severity, depression, and anxiety especially at 22 weeks.

This study was underpowered so it will be important to determine whether these findings are replicated in a larger study.

Important Points:
This study supports the feasibility of this opioid taper support intervention and its promise for efficacy in reducing prescription opioid doses without increases in pain intensity or pain interference. Opioid taper support thus may offer an important patient care strategy in combating the opioid epidemic.

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