Novel Intervention Helps Pain Patients Discontinue Opioids

Eve Bender

June 02, 2023

A novel intervention that blends individualized care, mindfulness, and a tapering plan is more successful than usual care in helping patients discontinue opioids for chronic pain, new research shows.

As part of the multisite Improving the Wellbeing of People with Opioid Treated Chronic Pain (I-WOTCH) study, 30% of participants in the intervention group were able to discontinue opioids vs 7% of those in the usual care group.

Lead investigator Harbinder Sandhu, DHealthPsy, assistant professor of health psychology at Warwick Medical School in Coventry, UK, said the benefits of the intervention included tailoring the plan to each participant.

"The tapering [regimen] and monitoring plan was individualized," Sandhu told Medscape Medical News. "Participants had the opportunity to consolidate their learning from the group sessions [with their tailored tapering plans], so the tapering speed was monitored and flexible if needed."

The findings were published online May 23 in the Journal of the American Medical Association.

Tapering, Mindfulness, and Coaching

Previous studies aimed at reducing chronic opioid use have been limited by poor methodology and a lack of safety data.

Participants in the current study were taking opioids to relieve nonmalignant pain for at least 3 months and almost daily for at least a month before the study started. The medications included buprenorphine, morphine, fentanyl, methadone, oxycodone, and tramadol.

The study included 608 participants from general medical practices (GP) in the northeast and midlands of England between 2017 and 2020. The mean age was 61 years, and 60% were female. The vast majority (96%) were White British.

Participants randomly assigned to receive usual care (n = 303) had access to their existing GP care and a self-help booklet on opioid management and a relaxation CD.

The intervention participants (n = 305) received the same, plus a 3-day group meeting held once weekly by a nurse trained in the intervention, a mindfulness CD, and coaching on distraction techniques.

In addition, participants received a 1-hour consultation with the nurse, two monitoring phone calls, an in-person consultation, and an individualized and flexible tapering plan.

As part of the intervention, investigators reduced 10% of the baseline opioid dose each week until the participant reached 30% of the dose. They then reduced that dose by 10% each week. Participants were assessed every 4 months for a year.

Optimism for Long-Term Abstinence

At baseline, 34% of the intervention group and 32% of the usual care group were taking the lowest dosage of opioids, categorized as a morphine equivalent of 0-29 mg per day, and 12% and 10%, respectively, were taking the highest dosage of opioids, categorized as ≥ 150 mg per day.

The investigators note that only 47% of those randomized to the intervention adhered to the full protocol.

At 4-month and 8-month follow-up, participants in the intervention group who cut their daily dose in half were statistically significant (P < .001).

By 12 months, study attrition left 225 in the intervention group and 208 in the usual care group.

A total of 65 participants (29%) in the intervention group discontinued their opiates, and 15 (7%) of those in the usual care group did (absolute difference, 21.7% [95% CI, 14.8% - 28.6%]; P < .001).

At the 4-month follow-up, participants receiving the intervention showed statistically significant improvement in mental health as demonstrated by scores on the SF-12 mental component score (P = .02).

Investigators measured pain in both groups using the PROMIS-PI-SF-8a and noted that pain scores remained fairly constant throughout the study, and there were no significant differences in pain reports at the 12-month mark between the two groups.

Serious adverse events occurred in 8% (25/305) of the participants in the intervention group and 5% (16/303) of the participants in the usual care group and included gastrointestinal and musculoskeletal issues.

Although there were four deaths in the intervention group, none were deemed to be related to the intervention, and included causes such as aortic dissection and metastatic cancer, Sadhu said.

Based on the results of the study, Sandhu said she is hopeful.

"We first observed the difference in the number of people stopping opioids in the intervention group at the four-month follow-up, with very few people re-starting opioids after this. We are therefore optimistic that those people who were still off opioids at 12 months will be able to remain opioid-free in the long term," she noted.

Study limitations included self-report as a means of recording opioid use (with results not validated by blood or urine samples). Neither study participants nor study coordinators were blind to study assignment.

The Critical Role of Social Connection

Commenting on the findings for Medscape Medical News, Aaron Greenblatt, MD, noted how challenging it is for patients to taper, or discontinue, long-term chronic opioid treatment, even if their opioid use does not satisfy the diagnostic criteria for opioid use disorder.

Dr Aaron Greenblatt

Greenblatt, who is medical director of the University of Maryland Medical Center (UMMC) Addiction Treatment Program and assistant professor of psychiatry, noted that the intervention included increased social connection and that this may be one of the key mechanisms responsible for its success. He noted that previous research has shown a link between social connection and effectively coping with chronic pain.

"It also in some ways represents a clinical remedy for the dynamic of growing social disconnectedness that has been blamed, in part, for the current opioid epidemic in the United States," Greenblatt said.

He added that self-reported pain among participants in the intervention group remained the same, even as their total opioid dose decreased.

"This is yet another confirmation that opioid analgesics simply are not that effective over the long-term for most people's chronic noncancer pain. Having said that, it's also incredibly important to note that abruptly tapering or discontinuing chronic opioid treatment introduces the potentially fatal risk of transition to street opioids, which is all the more life-threatening in the era of extra-medical fentanyl," said Greenblatt.

The I-WOTCH study was funded by the National Institute for Health and Care Research. Sandhu reported receiving grants from the National Institute for Health and Care Research and serving as director of Health Psychology Services Ltd.

JAMA. Published online May 23, 2023. Abstract

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