Brief Psychological Interventions for Reducing Prescription Opioid Use, Related Harm, and Pain Intensity in Patients With Chronic Pain: A Systematic Review and Assessment of Patient Interest

Applying Patient and Health Professional Preferences in Co-Designing a Digital Brief Intervention to Reduce the Risk of Prescription Opioid-Related Harm Among Patients With Chronic Noncancer Pain: Qualitative Analysis

BACKGROUND

Few personalized behavioral treatments are available to reduce the risk of prescription opioid-related harm among patients with chronic noncancer pain.

OBJECTIVE

We aimed to report on the second phase of the co-design of a digital brief intervention (BI) based on patient and health professional preferences.

METHODS

Eligible patients with chronic noncancer pain (n=18; 10 women; mean age 49.5, SD 6.91 y) from public hospital waitlists and health professionals (n=5; 2 women; mean age 40.2, SD 5.97 y) from pain and addiction clinics completed semistructured telephone interviews or participated in focus groups exploring BI preferences, needs, and considerations for implementation. Grounded theory was used to thematically analyze the data.

RESULTS

We identified 5 themes related to intervention content from patient reports: relevance of the biopsychosocial model and need for improved awareness and pain psychology education; nonpharmacological strategies and flexibility when applying coping skills training; opioid use reflection and education, with personalized medication and tapering plans; holistic and patient-inclusive assessment measures and feedback; and inclusion of holistic goals targeting comfort and happiness. Five themes related to the process and guiding principles were identified: therapist guided; engaging features; compassionate, responsive, person-centered care; a digital solution is exciting, maximizing reach; and educate and normalize system and policy challenges. Finally, 5 themes were reflected in the health professionals' reports: digital health use is rare but desired; digital health is useful for patient monitoring and accessing support; patient motivation is important; a digital BI app is likely beneficial and at multiple care points; and safe medication use and managing pain goals. The reported barriers from health professionals were intervention intensity, potential costs, and patient responsiveness; factors facilitating the implementation were the alignment of digital BIs with clinical models, a stepped-care approach, and feedback.

CONCLUSIONS

This co-design study identified key content areas, guiding principles, enabling factors, and barriers from both patients and health professionals to guide the development of digital BIs. The knowledge gathered should inform future iterations of co-designing digital BIs for the population most at risk of the harmful effects of opioid medications.

Co-Designing a Digital Brief Intervention to Reduce the Risk of Prescription Opioid-Related Harm Among People With Chronic Noncancer Pain: Qualitative Analysis of Patient Lived Experiences

BACKGROUND

Opioid medications are important for pain management, but many patients progress to unsafe medication use. With few personalized and accessible behavioral treatment options to reduce potential opioid-related harm, new and innovative patient-centered approaches are urgently needed to fill this gap.

OBJECTIVE

This study involved the first phase of co-designing a digital brief intervention to reduce the risk of opioid-related harm by investigating the lived experience of chronic noncancer pain (CNCP) in treatment-seeking patients, with a particular focus on opioid therapy experiences.

METHODS

Eligible patients were those aged between 18 and 70 years with CNCP at a clinically significant level of intensity (a score of ≥4 of 10). Purposive sampling was used to engage patients on public hospital waitlists via mail or through the treating medical specialist. Participants (N=18; n=10 women; mean age 49.5 years, SD 11.50) completed semistructured telephone interviews. Interviews were transcribed verbatim, thematically analyzed using grounded theory, and member checked by patients.

RESULTS

Eight overarching themes were found, listed in the order of their prominence from most to least prominent: limited treatment collaboration and partnership; limited biopsychosocial understanding of pain; continued opioid use when benefits do not outweigh harms; a trial-and-error approach to opioid use; cycles of hopefulness and hopelessness; diagnostic uncertainty; significant negative impacts tied to loss; and complexity of pain and opioid use journeys.

CONCLUSIONS

The findings of this study advance progress in co-designing digital brief interventions by actively engaging patient partners in their lived experiences of chronic pain and use of prescription opioid medications. The key recommendations proposed should guide the development of personalized solutions to address the complex care needs of patients with CNCP.

Primary care-based interventions for secondary prevention of opioid dependence in patients with chronic non-cancer pain taking pharmaceutical opioids: a systematic review

BACKGROUND

Globally, almost one-third of adults with chronic non-cancer pain (CNCP) are prescribed opioids. Prevention of opioid dependence among these patients is a public health priority.

AIM

To synthesise the evidence on the effectiveness of primary care-based interventions for secondary prevention of opioid dependence in patients with CNCP who are taking pharmaceutical opioids.

DESIGN & SETTING

Systematic review of randomised controlled trials (RCTs) and comparative non-randomised studies of interventions from high-income countries.

METHOD

We searched five databases for studies on non-tapering secondary prevention interventions, such as tools for predicting dependence, screening tools for early recognition of dependence, monitoring of prescribing or medication, and specialist support. We examined multiple outcomes, including reduction in opioid dosage. Primary analyses were restricted to RCTs with data synthesised using an effect direction plot. Risk of bias was assessed using the Cochrane risk of bias (RoB2) tool.

RESULTS

Of 7102 identified reports, 18 studies were eligible (eight of which were RCTs). Most used multiple interventions or components. Of the seven RCTs at low risk of bias or with 'some concerns', five showed a positive intervention effect on at least one relevant outcome, four of which included a nurse care manager and/or other specialist support. The remaining two RCTs showed no positive effect of automated symptom monitoring and optimised analgesic management by a nurse care manager or a physician pain specialist team, or of a mobile opioid management app.

CONCLUSION

We identify a clear need for further adequately powered high-quality studies. The conclusions that can be drawn on the effectiveness of interventions are limited by the sparsity and inconsistency of available data.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management

OBJECTIVE

Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids.

METHODS

Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management.

RESULTS

There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant.

DISCUSSION

The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

Chronic pain experience through COVID-19: a comparison of reports prior and during the early stages of the pandemic

ABSTRACT

The impacts of COVID-19 and imposed restrictions on individuals with chronic noncancer pain continue to emerge, varying across countries. More recent research (including with longitudinal designs) suggests that the pandemic may not have such a disproportionate effect on chronic noncancer pain and its management as first thought. This longitudinal study, with assessments before the pandemic (2019) and early during the pandemic (May-July 2020), examined changes in validated measures of pain severity, pain interference, prescription opioid misuse, and mental health symptoms. Patients (N = 236) self-reported significant improvements in pain severity, pain interference, pain self-efficacy, pain catastrophizing, prescription opioid misuse, depression, and anxiety symptoms over time. Approximately 30% and 33% of patients achieved minimally important reductions (10% change) in pain severity and pain interference, respectively. In follow-up exploratory analyses, prepandemic sociodemographic and psychological factors predictive of 10% improved (vs 10% worse) pain severity and interference were investigated in logistic regressions. Reduction in pain interference was predicted by current employment, older age, and higher pain self-efficacy. There were no significant predictors of reduction in pain severity. The impact of COVID-19 on patients' pain experience and mental health was negligible in the early stages of the pandemic, and findings suggest improvements through the period. Targeted interventions that promote the protective factor of pain self-efficacy and build resilience may buffer patients' future response to the pandemic because it evolves as a part of our new normal. Targeted social determinants of health interventions that direct resources toward maintaining employment could also be important.

Feasibility study of a Behavioural Intervention for Opioid Reduction (BIOR) for patients with chronic non-cancer pain in primary care: a protocol

INTRODUCTION

Around 30%-50% of adults suffer moderate to severe chronic pain not caused by cancer. Significant numbers are treated with opioids which over time may cease to be effective and produce side effects (eg, nausea, drowsiness and constipation). Stopping taking opioids abruptly can cause unpleasant withdrawal effects. Tapering in small steps is recommended, though some patients might struggle and need support, particularly if they have limited access to pain management alternatives. Awareness of the potential risks as well as benefits of tapering should be explored with patients.

METHODS AND ANALYSIS

A randomised controlled pilot feasibility study to investigate the effectiveness and feasibility of reducing high doses of opioids through a tapering protocol, education and support in primary care. Working with NHS Knowsley Place, we will identify patients taking 50 mg or above morphine equivalent dose of opioids per day to be randomly allocated to either the tapering group or tapering with support group. At an initial joint appointment with a pain consultant and General Practitioner (GP) GP tapering will be discussed and negotiated. Both groups will have their opioid reduced by 10% per week. The taper with support group will have access to additional support, including motivational counselling, realistic goal setting and a toolkit of resources to promote self-management. Some patients will successfully reduce their dose each week. For others, this may be more difficult, and the tapering reduction will be adjusted to 10% per fortnight. We assess opioid use, pain and quality of life in both groups at the start and end of the study to determine which intervention works best to support people with chronic pain who wish to stop taking opioids.

ETHICS AND DISSEMINATION

The Behavioural Intervention for Opioid Reduction feasibility study has been granted full approval by Liverpool Central Research Ethics Committee on 7 April 2022 (22/NW/0047). The current protocol version is V.1.1, date 6 July 2022. Results will be published in peer-reviewed journals and disseminated to patient stakeholders in a lay summary report available on the project website and in participating GP surgeries.

TRIAL REGISTRATION NUMBER

ISRCTN 30201337.

Identifying harm reduction strategies for alcohol and drug-use in inpatient care settings and emergency departments: a scoping review protocol

INTRODUCTION

People who use alcohol and/or drugs (PWUAD) are at high risk of medical complications, frequent hospitalisation and drug-related death following discharge from inpatient settings and emergency departments (EDs). Harm reduction strategies implemented in these settings may mitigate negative health outcomes for PWUAD. However, the scope of harm reduction strategies used globally within inpatient settings and EDs is unknown. The objective of this review is to identify and synthesise reported harm reduction strategies that have been implemented across inpatient settings and EDs for PWUAD.

METHODS AND ANALYSIS

This review will include studies from any country and health service reporting on harm reduction strategies implemented in inpatient settings or EDs. The population of interest includes people of any race, gender and age identifying as PWUAD, or individuals who provided care to PWUAD. Studies which describe implementation strategies and barriers and enablers to implementation will be included. Studies published in English, or those available for English translation will be included. The following databases will be searched: MEDLINE All (Ovid), Embase (Elsevier Embase.com), CINAHL with Full Text (EBSCOhost), PsycINFO (EBSCOhost) and SCOPUS (Elsevier Scopus.com). A grey literature search will be conducted. There will be no date restrictions on the search. Titles, abstracts and full texts will be screened in duplicate. Data will be extracted using a standardised form. The results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews.

ETHICS AND DISSEMINATION

Scoping reviews do not require ethical approval. Patient partners with lived experience and relevant knowledge users will be engaged as research team members throughout all phases of the research process. A report detailing context, methodology and findings from this review will be disseminated to knowledge users and relevant community stakeholders. This review will be submitted for publication to a relevant peer-reviewed journal.

Pain Medication Beliefs Mediate the Relationship Between Pain Catastrophizing and Opioid Prescription Use in Patients With Chronic Non-Cancer Pain

Little is known about the mechanisms by which pain catastrophizing may be associated with opioid use outcomes. This study aimed to investigate the potential mediating role of beliefs about the appropriateness of pain medicines for pain treatment on the association between pain catastrophizing and prescription opioid use in a community chronic non-cancer pain (CNCP) sample. Individuals (N = 420) diagnosed with CNCP participated in a cross-sectional online self-report study with validated measures of pain medication beliefs, pain catastrophizing, and current prescription opioid use. Two parallel multiple mediator analyses with percentile-based bootstrapping examined pathways to both prescription opioid use and high-dose use (≥ 100mg oral morphine equivalents/day), while controlling for pain intensity and other relevant covariates. Pain medication beliefs significantly mediated the association between pain catastrophizing and prescription opioid use (CI = 0.011, 0.033). A similar pattern of findings was found for high-dose opioid use, with pain medication beliefs significantly mediating the pain catastrophizing-high-dose use association (CI = 0.006, 0.050). Pain medication beliefs are a potentially modifiable psychological mechanism by which pain catastrophizing is associated with opioid use, including high-dose use. These findings have important implications for personalizing prevention and treatment programs.