STRategies to Improve Pain and Enjoy life (STRIPE): results of a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy

Management of patients at risk of harms from both continuing and discontinuing their long-term opioid therapy: A qualitative study to inform the gap in clinical practice guidelines

BACKGROUND

Although long-term opioid therapy (LTOT) for chronic pain has declined, it remains common in the U.S. Providers do not have clinical practice guidelines for vulnerable LTOT patients, in whom both LTOT continuation and tapering to discontinuation pose risks of harm and in whom opioid use disorder (OUD) is absent.

METHODS

To begin to meet the gap in guidelines, the study used a multiple case study approach. Five cases were constructed to systematically vary key elements of LTOT continuation and discontinuation harms among patients reporting LTOT's lack of efficacy (experience of pain and poor function). For each, treatment approaches were collected from 28 opioid safety experts identified through their participation in a national policy panel (19 were physicians) and analyzed using template analysis.

RESULTS

For patients receiving LTOT with harms of continuation and discontinuation, experts recommended attempting a slow taper (even with a prior unsuccessful taper, possibly with adjuvant medications to manage withdrawal) and not maintaining opioid therapy. Experts considered switching to buprenorphine, especially if the patient had aberrant behaviors. They also considered adding non-opioid pain therapies (especially re-trying such therapies if they were unhelpful before) and engaging in shared decisionmaking, although with little consensus on specific approaches. Some experts would address co-occurring conditions related to patient safety (alcohol use, mental health symptoms, opioid side effects). Few experts referenced assessing or addressing OUD or overdose risk. In quantitative data, 36% of experts agreed LTOT is beneficial, 36% agreed most LTOT patients should be discontinued, and 57% agreed patients experience harm from tapering and from discontinuation.

DISCUSSION

Evidence is needed to build on and test these experts' recommendations to attempt tapering and add non-opioid pain therapies for patients reporting harms of continued LTOT who may experience harms from tapering. Such evidence informs the development of clinical practice guidelines that provide comprehensive protocols to support the safety and functioning of this group of patients.

The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review

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.

Medical-surgical patients with untreated hazardous drinking: Randomized controlled trial of the DO-MoST intervention to improve health outcomes over 12-month follow-up

INTRODUCTION

High prevalence and harmful consequences of hazardous drinking among medical-surgical patients underscore the importance of intervening with drinking to improve patients' health. This study evaluated a novel intervention, "Drinking Options - Motivate, Shared Decisions, Telemonitor" (DO-MoST).

METHODS

In a randomized design, 155 medical-surgical patients with untreated hazardous drinking were assigned to enhanced usual care or DO-MoST, and followed 3, 6, and 12 months later. We conducted intent-to-treat and per-protocol analyses.

RESULTS

For the primary outcome, percent days of alcohol abstinence in the past 30 days, intent-to-treat analyses did not find superior effectiveness of DO-MoST. However, per-protocol analyses found abstinence increased between 3 and 12 months among participants assigned to DO-MoST who engaged with the intervention (n=46). Among DO-MoST-assigned participants who did not engage (n=27), abstinence stayed stable during follow-up. Group comparisons showed an advantage on abstinence for Engaged compared to Non-Engaged participants on change over time. Intent-to-treat analyses found that DO-MoST was superior to usual care on the secondary outcome of physical health at 12 months; per-protocol analyses found that Engaged DO-MoST-assignees had better physical health at 12 months than Non-Engaged DO-MoST-assignees. DO-MoST-assignees had lower odds of receiving substance use care during follow-up than usual care-assignees.

DISCUSSION

Patients engaged in DO-MoST showed a greater degree of abstinence and better physical health relative to the non-engaged or usual care group. DO-MoST may be a source of alcohol help in itself rather than only a linkage intervention. Work is needed to increase DO-MoST engagement among medical-surgical patients with untreated hazardous drinking.