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Coffee Z, Cheng K, Slebodnik M, Mulligan K, Yu CH, Vanderah TW, Gordon JS. The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:794. [PMID: 38929040 PMCID: PMC11203961 DOI: 10.3390/ijerph21060794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/06/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.
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Affiliation(s)
- Zhanette Coffee
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
| | - Kevin Cheng
- College of Medicine, University of Arizona, Tucson, AZ 85721, USA;
| | | | - Kimberly Mulligan
- Veterans Health Administration, Central California, Fresno, CA 93706, USA
| | - Chong Ho Yu
- Department of Mathematics, Hawaii Pacific University, Honolulu, HI 96813, USA;
| | - Todd W. Vanderah
- Department of Pharmacology, Comprehensive Center for Pain and Addiction, University of Arizona, Tucson, AZ 85721, USA;
| | - Judith S. Gordon
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
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Nickerson K, Lieschke G, Rajappa H, Smith A, Inder KJ. A scoping review of outpatient interventions to support the reduction of prescription opioid medication for chronic non cancer pain. J Clin Nurs 2022; 31:3368-3389. [PMID: 35132707 PMCID: PMC9790561 DOI: 10.1111/jocn.16235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/27/2021] [Accepted: 01/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prescription opioid use is a global health issue. Previous systematic reviews have not identified that any specific intervention supports prescription opioid reduction effectively. In keeping with the nature of a scoping review, this review details an overview of the existing literature on this topic, with quality of evidence being discussed rather than formally analysed. AIM This review aimed to examine and describe outpatient interventions that support the reduction of prescription opioid medication for chronic non cancer pain. ELIGIBILITY CRITERIA Abstracts were reviewed against the inclusion criteria of outpatient clinical interventions, for the purpose of prescription opioid dose reduction, offered to adults with CNCP. SOURCES OF EVIDENCE Following a structured review approach an electronic database search, of Medline, Embase, Cochrane, Cinahl, and Proquest and grey literature was undertaken. Search results were screened by title for relevance. CHARTING METHODS Two reviewers adhering to the PRISMA-ScR checklist charted and assessed studies for quality using Critical Appraisal Skills Programme checklist assessment tools. Extracted data were collated and synthesised for presentation as a tabular and narrative review. RESULTS From the initial search of 5089 papers, 19 underwent full-text review and quality appraisal. A variety of interventions were described to support reduction in prescription opioid use, however only one study of at least fair quality was able to demonstrate a demonstrated a statistically significant benefit in reducing measured opioid dose compared with a control group. Interventions were implemented in both specialist pain services and in primary care with multidisciplinary and interdisciplinary clinician care. Barriers and facilitators were observed in both settings. CONCLUSION AND IMPLICATIONS FOR CLINICAL PRACTICE Further rigorous research needs to be conducted to conclusively answer the question of what outpatient interventions support opioid reduction in chronic non cancer pain. This scoping review is the first step of inquiry in the development of a nursing intervention to support reduction of prescription opioids.
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Affiliation(s)
- Kathie Nickerson
- Hunter Integrated Pain ServiceHunter New England Local Health DistrictNew LambtonNew South WalesAustralia,School of Nursing and MidwiferyUniversity of NewcastleCallaghanNew South WalesAustralia
| | - Gena Lieschke
- Hunter Integrated Pain ServiceHunter New England Local Health DistrictNew LambtonNew South WalesAustralia,School of Nursing and MidwiferyUniversity of NewcastleCallaghanNew South WalesAustralia,Nursing and Midwifery Research CentreHunter New England Health Local Health DistrictNewcastleNew South WalesAustralia
| | - Hema Rajappa
- Hunter Integrated Pain ServiceHunter New England Local Health DistrictNew LambtonNew South WalesAustralia,School of Medicine and Public HealthUniversity of NewcastleCallaghanNew South WalesAustralia,Hunter Medical Research InstituteNew LambtonNew South WalesAustralia
| | - Angela Smith
- Hunter New England Health LibrariesNew LambtonNew South WalesAustralia
| | - Kerry Jill Inder
- School of Nursing and MidwiferyUniversity of NewcastleCallaghanNew South WalesAustralia,Hunter Medical Research InstituteNew LambtonNew South WalesAustralia
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Fillipo R, Pruka K, Carvalho M, Horn ME, Moore J, Ramger B, Clewley D. Does the implementation of clinical practice guidelines for low back and neck pain by physical therapists improve patient outcomes? A systematic review. Implement Sci Commun 2022; 3:57. [PMID: 35659117 PMCID: PMC9164354 DOI: 10.1186/s43058-022-00305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physical therapy for neck and low back pain is highly variable despite the availability of clinical practice guidelines (CPG). This review aimed to determine the impact of CPG implementation on patient-level outcomes for spinal pain. Implementation strategies were also examined to determine prevalence and potential impact. METHODS Multiple databases were searched through April 2021 for studies assessing CPG implementation in physical therapy for neck and low back pain. Articles were screened for eligibility. The Modified Downs and Black checklist was utilized to determine study quality. Due to the heterogeneity between studies, a meta-analysis was not performed. RESULTS Twenty-one studies were included in this review. Implementation strategies were significantly varied between studies. Outcomes pertaining to healthcare utilization, pain, and physical functioning were assessed in relation to the implementation of CPGs. Multiple implementation strategies were identified, with Managing Quality as the most frequently utilized key implementation process. Findings indicate CPG implementation decreased healthcare utilization, but inconsistent results were found with physical functioning and pain outcomes. CONCLUSIONS CPG implementation appears to have a beneficial effect on healthcare utilization outcomes, but may not impact pain and physical functioning outcomes. Effective CPG implementation strategies remain unknown, though utilizing implementation framework may improve outcomes. More research is needed to determine the most effective implementation strategies and effects on pain and physical function outcomes.
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Affiliation(s)
- Rebecca Fillipo
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA.
| | - Katie Pruka
- Department of Outpatient Rehabilitation, Duke University Health System, Durham, North Carolina, USA
| | - Marissa Carvalho
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA
| | - Maggie E Horn
- Division of Doctor of Physical Therapy, Department of Orthopaedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Jordan Moore
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA
| | - Benjamin Ramger
- Department of Outpatient Rehabilitation, Duke University Health System, Durham, North Carolina, USA
| | - Derek Clewley
- Division of Doctor of Physical Therapy, Department of Orthopaedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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5
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Westenberg JN, Tai AMY, Elsner J, Kamel MM, Wong JSH, Azar P, Vo DX, Moore E, Mathew N, Seethapathy V, Choi F, Vogel M, Krausz RM. Treatment approaches and outcome trajectories for youth with high-risk opioid use: A narrative review. Early Interv Psychiatry 2022; 16:207-220. [PMID: 33913589 DOI: 10.1111/eip.13155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/22/2021] [Indexed: 12/26/2022]
Abstract
AIM First use of opioids often happens in adolescence and an increasing number of opioid overdoses are being reported among youth. The purpose of this narrative review was to present the treatment approaches for youth with high-risk opioid use, determine whether the literature supports the use of opioid agonist treatment among youth and identify evidence for better treatment outcomes in the younger population. METHODS A search of the literature on PubMed using MeSH terms specific to youth, opioid use and treatment approaches generated 1436 references. Following a screening process, 137 papers were found to be relevant to the treatment of high-risk opioid use among youth. After full-text review, 19 eligible studies were included: four randomized controlled trials, nine observational studies and six reviews. RESULTS Research for the different treatment options among youth is limited. The available evidence shows better outcomes in terms of retention in care and cost-effectiveness for opioid agonist treatment than abstinence-based comparisons. Integrating psychosocial interventions into the continuum of care for youth can be an effective way of addressing comorbid psychiatric conditions and emotional drivers of substance use, leading to improved treatment trajectories. CONCLUSIONS From the limited findings, there is no evidence to deny youth with high-risk opioid use the same treatment options available to adults. A combination of pharmacological and youth-specific psychosocial interventions is required to maximize retention and survival. There is an urgent need for more research to inform clinical strategies toward appropriate treatment goals for such vulnerable individuals.
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Affiliation(s)
- Jean Nicolas Westenberg
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andy M Y Tai
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Elsner
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mostafa M Kamel
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Neuropsychiatry, Tanta University, Tanta, Egypt
| | - James S H Wong
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pouya Azar
- Complex Pain and Addiction Services, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Dzung X Vo
- Division of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Eva Moore
- Division of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Nickie Mathew
- Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Vijay Seethapathy
- Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Fiona Choi
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marc Vogel
- Psychiatric University Clinic Basel, Basel, Switzerland
| | - Reinhard M Krausz
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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6
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Silva MJ, Coffee Z, Yu CH, Martel MO. Anxiety and Fear Avoidance Beliefs and Behavior May Be Significant Risk Factors for Chronic Opioid Analgesic Therapy Reliance for Patients with Chronic Pain-Results from a Preliminary Study. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:2106-2116. [PMID: 33595642 PMCID: PMC8427345 DOI: 10.1093/pm/pnab069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe differences between patients with chronic, non-cancer pain (CNCP) who were successfully able to cease full mu agonist chronic opioid analgesic therapy (COAT), and those who exhibited refractory COAT reliance, among those who participated in a multidisciplinary program designed for COAT cessation. DESIGN A retrospective review of electronic medical records (EMR) data was organized for preliminary analysis. SETTING A multicenter private practice specializing in CNCP, which received patient referrals from the surrounding geographical area of primary and specialty care offices in Northern California. SUBJECTS Data from 109 patients with CNCP who participated in a multidisciplinary program to cease COAT between the dates of October 2017 to December 2019 were examined. METHODS EMR data, pre-COAT cessation, of oral morphine milligram equivalence (MME) and validated questionnaire responses assessing anxiety and fear-based beliefs and behavior, as well as opioid misuse, were extracted and compared between those who successfully ceased COAT and those who did not. RESULTS Patients who were unsuccessful at COAT cessation reported significantly higher Fear Avoidance Beliefs Questionnaire (FAB) scores. No significant differences were found based on incoming MME amounts, Current Opioid Misuse Measure (COMM) or Tampa Scale of Kinesiophobia (TSK) scores. Pain Catastrophizing Scale (PCS) scores showed a split pattern with unclear significance. CONCLUSIONS Results suggest that fear avoidance beliefs and behavior, as measured by the FAB, play a significant role in refractory COAT reliance for patients with CNCP.
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Affiliation(s)
- Marcelina Jasmine Silva
- Founder and former Medical Director of The Focus on Opioid Transitions Program, Integrated Pain Management Medical Group Inc, Walnut Creek, California, USA
| | - Zhanette Coffee
- College of Nursing, University of Arizona, Tucson, Arizona, USA
| | - Chong Ho Yu
- Department of Behavioral and Applied Science, Azusa Pacific University, Azusa, California, USA
| | - Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Quebec, Canada
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Brintz CE, Cheatle MD, Dember LM, Heapy AA, Jhamb M, Shallcross AJ, Steel JL, Kimmel PL, Cukor D. Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease. Semin Nephrol 2021; 41:68-81. [PMID: 33896475 DOI: 10.1016/j.semnephrol.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.
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Affiliation(s)
- Carrie E Brintz
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alicia A Heapy
- Pain Research Informatics Multimorbidities and Education Center of Innovation, Veterans' Affairs Connecticut Healthcare System, West Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amanda J Shallcross
- Department of Population Health, New York University School of Medicine, New York, NY
| | - Jennifer L Steel
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA; Department of Psychology, University of Pittsburgh, Pittsburgh, PA; Behavioral Health, The Rogosin Institute, New York, NY
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Daniel Cukor
- Behavioral Health, The Rogosin Institute, New York, NY
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Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain: a Rapid Review. J Gen Intern Med 2020; 35:935-944. [PMID: 33145689 PMCID: PMC7728933 DOI: 10.1007/s11606-020-06253-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/17/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide. METHODS We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking. RESULTS We included 49 studies-1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown. DISCUSSION The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm.
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Ocker AC, Shah NB, Schwenk ES, Witkowski TA, Cohen MJ, Viscusi ER. Ketamine and Cognitive Behavioral Therapy for Rapid Opioid Tapering With Sustained Opioid Abstinence: A Case Report and 1‐Year Follow‐up. Pain Pract 2019; 20:95-100. [DOI: 10.1111/papr.12829] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Aaron C. Ocker
- Thomas Jefferson University Hospital Philadelphia Pennsylvania U.S.A
| | - Nirmal B. Shah
- Thomas Jefferson University Hospital Philadelphia Pennsylvania U.S.A
| | - Eric S. Schwenk
- Department of Anesthesiology Sidney Kimmel Medical College Thomas Jefferson University Philadelphia Pennsylvania U.S.A
| | - Thomas A. Witkowski
- Department of Anesthesiology Sidney Kimmel Medical College Thomas Jefferson University Philadelphia Pennsylvania U.S.A
| | - Mitchell J. Cohen
- Department of Psychiatry Sidney Kimmel Medical College Thomas Jefferson University Philadelphia Pennsylvania U.S.A
| | - Eugene R. Viscusi
- Department of Anesthesiology Sidney Kimmel Medical College Thomas Jefferson University Philadelphia Pennsylvania U.S.A
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Shechter R, Speed TJ, Blume E, Singh S, Williams K, Koch CG, Hanna MN. Addressing the Opioid Crisis One Surgical Patient at a Time: Outcomes of a Novel Perioperative Pain Program. Am J Med Qual 2019; 35:5-15. [DOI: 10.1177/1062860619851170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Opioid prescriptions in the surgical setting have been implicated as contributors to the opioid epidemic. The authors hypothesized that a multidisciplinary approach to perioperative pain management for patients on chronic opioid therapy could decrease postoperative opioid requirements while reducing postoperative pain scores and improving functional outcomes. Therefore, a Perioperative Pain Program (PPP) for chronic opioid users was implemented. This study presents outcomes from the first 9 months of the PPP. Sixty-one patients met the inclusion criteria. Opioid consumption in morphine milligram equivalent (MME) was calculated and physical and health status of patients was assessed with the Brief Pain Inventory, Short-Form McGill Pain Questionnaire, and Short Form-12. Preliminary results showed significant reduction in MME, improved pain scores, and improved function for surgical patients on chronic opioids. PPP effectively reduced opioid usage without negatively influencing patient-reported outcomes, such as physical pain score assessment and health-related quality of life.
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11
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Selecting the Appropriate Patient for Opioid Therapy: Risk Assessment and Treatment Strategies for Gynecologic Pain. Clin Obstet Gynecol 2019; 62:48-58. [DOI: 10.1097/grf.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Bienek N, Maier C, Kaisler M, Michel-Lauter B, Schwarzer A, Meyer-Frießem CH. Intensity of Withdrawal Symptoms During Opioid Taper in Patients with Chronic Pain—Individualized or Fixed Starting Dosage? PAIN MEDICINE 2019; 20:2438-2449. [DOI: 10.1093/pm/pny320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AbstractObjectiveControlled opioid withdrawal is recommended for patients with chronic noncancer pain (CNCP) with insufficient pain reduction or intolerable side effects while on opioid treatment. Few studies have investigated the management of opioid withdrawal (OW). Most common are protocols with an individualized starting dosage (ISD), calculated from the last opioid intake. After two cases of overdose, we introduced a novel withdrawal protocol using a low fixed starting dosage (FSD) for safety reasons. The present study compares the intensity of withdrawal symptoms using the Subjective Opioid Withdrawal Scale (SOWS) and incidences of serious adverse events (SAE) and dropouts in each taper schedule in 195 CNCP patients with OW in an inpatient facility.MethodsTwo protocols were compared: FSD (2014–2016): N = 68, starting dose: 90 mg morphine/d; and ISD (2010–2014): N = 127, starting dose: 70% of the patient’s daily morphine equivalent dose (MED). Outcome criteria: primary: mean daily SOWS score during the first 10 days (16 questions, daily score 0–64); secondary: change in pain intensity on a numeric rating scale (0–10), rate of dropouts and SAEs. Statistics: Student test, Mann-Whitney U test, chi-square test, analysis of variance, P < 0.05.ResultsThe mean daily SOWS score was lower in the FSD group (14.9 ± 9.4 vs 16.1 ± 10, P < 0.05) due to a lower rate of high-intensity withdrawal symptoms (12.4% vs 17.6%, P < 0.01), particularly in patients on >180 mg MED (9.7% vs 18.4%, P < 0.01). Pain intensity decreased after withdrawal, and the incidence of SAEs and dropouts was low in both groups.ConclusionsThe FSD protocol provides a lesser burden of withdrawal symptoms and equal patient safety. It can be recommended for OW in CNCP patients.
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Affiliation(s)
- Natalia Bienek
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology and Intensive Care, Klinikum Dortmund, Dortmund, Germany
| | | | | | | | | | - Christine H Meyer-Frießem
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain Management, Medical Faculty of Ruhr-University Bochum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH Bochum, Bochum, Germany
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Fishbain DA, Pulikal A. Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. PAIN MEDICINE 2018; 20:2179-2197. [DOI: 10.1093/pm/pny231] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Objective
To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.
Methods
Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.
Results
No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.
Conclusions
There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry
- Departments of Neurological Surgery
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
| | - Aditya Pulikal
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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Pergolizzi JV, Rosenblatt M, Mariano DJ, Bisney J. Tapering opioid therapy: clinical strategies. Pain Manag 2018; 8:409-413. [PMID: 30394191 DOI: 10.2217/pmt-2018-0040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
| | - Melanie Rosenblatt
- Pain Management Strategies, Pompano Beach, Florida & Co-founder of MelRose Pain Solutions, Naples, FL, USA
| | - Dean J Mariano
- Mariano Medical LLC, Pain/Addiction Consultants, West Hartford, CT, USA
| | - John Bisney
- NEMA Research Inc. & Co-founder of MelRose Pain Solutions, Naples, FL, USA
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Wenger S, Drott J, Fillipo R, Findlay A, Genung A, Heiden J, Bradt J. Reducing Opioid Use for Patients With Chronic Pain: An Evidence-Based Perspective. Phys Ther 2018; 98:424-433. [PMID: 29669085 DOI: 10.1093/ptj/pzy025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 02/09/2018] [Indexed: 02/09/2023]
Abstract
The implementation of recent Centers for Disease Control and Prevention recommendations to move away from opioids and toward nonpharmacological therapies for the treatment of chronic pain could involve a difficult transition period for patients and practitioners. The focus of treatment should shift from eliminating pain completely to minimizing the impact of pain on quality of life. Many patients with chronic pain take opioids either because opioids were previously prescribed as a first-line treatment for chronic pain, on the basis of old standards of care, or because opioids were initially prescribed for acute pain. Patients currently taking opioids will need a tapering period during which they transition their pain management to interdisciplinary care and nonpharmacological treatments. To provide useful treatment options, physical therapists need to have a good understanding of the neuroscientific mechanisms of chronic pain, biopsychosocial components of chronic pain management, issues related to opioid use, and pain management strategies used by other health care professionals. Armed with knowledge and good communication skills, physical therapists can work within an interdisciplinary team to adapt care to each patient's needs and abilities. This perspective article provides guidance for physical therapists to effectively treat patients with chronic pain during the opioid tapering process. A framework has been created to help health care providers structure their reasoning as they collaborate to develop a unique approach for each patient.
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Affiliation(s)
- Sarah Wenger
- Department of Physical Therapy and Rehabilitation, Drexel University, 1601 Cherry Street, Room 758, MS 7-502, Philadelphia, PA 19102 (USA). Dr Wenger is a board-certified orthopaedic clinical specialist
| | - Jason Drott
- Department of Physical Therapy and Rehabilitation, Drexel University
| | - Rebecca Fillipo
- Department of Physical Therapy and Rehabilitation, Drexel University
| | - Alyssa Findlay
- Department of Physical Therapy and Rehabilitation, Drexel University
| | - Amanda Genung
- Department of Physical Therapy and Rehabilitation, Drexel University
| | - Jessica Heiden
- Department of Physical Therapy and Rehabilitation, Drexel University
| | - Joke Bradt
- Department of Creative Arts Therapies, Drexel University. Dr Bradt is a board-certified music therapist
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16
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Nielsen S, MacDonald T, Johnson JL. Identifying and treating codeine dependence: a systematic review. Med J Aust 2018; 208:451-461. [DOI: 10.5694/mja17.00749] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/19/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW
| | - Tim MacDonald
- Currumbin Clinic, Gold Coast, QLD
- Griffith University, Gold Coast, QLD
| | - Jacinta L Johnson
- University of South Australia, Adelaide, SA
- Southern Adelaide Local Health Network, Adelaide, SA
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Abstract
Supplemental Digital Content is Available in the Text. This descriptive case series among adults documents that pain can return temporarily at healed, previously pain-free injury sites during acute opioid withdrawal. Withdrawal pain can be a barrier to opioid cessation. Yet, little is known about old injury site pain in this context. We conducted an exploratory mixed-methods descriptive case series using a web-based survey and in-person interviews with adults recruited from pain and addiction treatment and research settings. We included individuals who self-reported a past significant injury that was healed and pain-free before the initiation of opioids, which then became temporarily painful upon opioid cessation—a phenomenon we have named withdrawal-associated injury site pain (WISP). Screening identified WISP in 47 people, of whom 34 (72%) completed the descriptive survey, including 21 who completed qualitative interviews. Recalled pain severity scores for WISP were typically high (median: 8/10; interquartile range [IQR]: 2), emotionally and physically aversive, and took approximately 2 weeks to resolve (median: 14; IQR: 24 days). Withdrawal-associated injury site pain intensity was typically slightly less than participants' original injury pain (median: 10/10; IQR: 3), and more painful than other generalized withdrawal symptoms which also lasted approximately 2 weeks (median: 13; IQR: 25 days). Fifteen surveyed participants (44%) reported returning to opioid use because of WISP in the past. Participants developed theories about the etiology of WISP, including that the pain is the brain's way of communicating a desire for opioids. This research represents the first known documentation that previously healed, and pain-free injury sites can temporarily become painful again during opioid withdrawal, an experience which may be a barrier to opioid cessation, and a contributor to opioid reinitiation.
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Teckchandani S, Barad M. Treatment Strategies for the Opioid-Dependent Patient. Curr Pain Headache Rep 2017; 21:45. [DOI: 10.1007/s11916-017-0644-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Berna C, Kulich RJ, Rathmell JP. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice. Mayo Clin Proc 2015; 90:828-42. [PMID: 26046416 DOI: 10.1016/j.mayocp.2015.04.003] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/31/2015] [Accepted: 04/07/2015] [Indexed: 11/22/2022]
Abstract
Increasing concern about the risks and limited evidence supporting the therapeutic benefit of long-term opioid therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids. In addition to overt addiction or diversion, the presence of adverse effects, diminishing analgesia, reduced function and quality of life, or the absence of progress toward functional goals can justify an attempt at weaning patients from long-term opioid therapy. However, discontinuing opioid therapy is often hindered by patients' psychiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers. The aim of this article is to review the existing literature and formulate recommendations for practitioners aiming to discontinue long-term opioid therapy. Specifically, this review aims to answer the following questions: What is an optimal opioid tapering regimen? How can the risks involved in a taper be managed? What are the alternatives to an opioid taper? A PubMed literature search was conducted using the keywords chronic pain combined with opioid withdrawal, taper, wean and detoxification. Six hundred ninety-five documents were identified and screened; 117 were deemed directly relevant and are included. On the base of this literature review, this article proposes evidence-based recommendations and expert-based suggestions for clinical practice. Furthermore, areas of lack of evidence are identified, providing opportunities for further research.
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Affiliation(s)
- Chantal Berna
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ronald J Kulich
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Tufts University School of Dental Medicine, Boston, MA
| | - James P Rathmell
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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Abstract
Clinicians are increasingly being challenged by patients who are treated for chronic pain with high-dose opioids that can cause medical, social, and societal harm. These patients may best be improved by psychological approaches, adjuvant medications, and opioid reduction or removal, rather than ever-escalating dosing that has become common. Opioid reduction or removal can be a difficult process that, when done incorrectly, may cause patient dissatisfaction or severe discomfort. Buprenorphine, a partial opioid agonist, is slowly becoming recognized as an effective pain treatment, possessing a wide safety margin while offering the opportunity for stabilization of opioid dosing or even removal. We have developed a protocol for hospitalization of the most fragile or toxic patients detailed herein that can permit a comfortable conversion to buprenorphine from prior high-dose full agonist opioid therapy. Seventy-six consecutive patients with serious medical, psychological, or addiction comorbidities, treated with morphine equivalent doses exceeding hundreds of milligrams per day, were followed after conversion for up to 25 months. Two-thirds reported moderate to dramatic improvements of pain and functional status with an increase seen in employment. Median length of hospital stay was 2 days, and the median daily buprenorphine discharge dose was 8 mg. No adverse reactions or outcomes were observed. A brief hospitalization for conversion from high-dose opioid therapy to a safer, more effective buprenorphine regimen can produce life-altering improvement.
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21
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Current world literature. Curr Opin Support Palliat Care 2011; 5:174-83. [PMID: 21521986 DOI: 10.1097/spc.0b013e3283473351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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