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Wu J, Yang P, Wu X, Yu X, Zeng F, Wang H. Analysis of physical activity and prescription opioid use among US adults: a cross-sectional study. BMC Public Health 2024; 24:698. [PMID: 38443876 PMCID: PMC10913271 DOI: 10.1186/s12889-024-18220-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/26/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Opioid crisis has become a global concern, but whether physical activity (PA) can effectively reduce prescription opioid use remains unclear. The study aimed to examine the relationship of different domains of PA (e.g., occupation-related PA [OPA], transportation-related PA [TPA], leisure-time PA [LTPA]) with prescription opioid use and duration of prescription opioid use. METHODS This cross-sectional study was conducted on 27,943 participants aged ≥ 18 years from National Health and Nutrition Examination Survey (NHANES, 2007- March 2020). We examined the relationship of different domains of PA with prescription opioid use and duration of prescription opioid use using multivariable logistic regression. Stratified analysis and a series of sensitivity analysis were used to elevate robustness. All analyses were conducted using appropriate sampling weights. RESULTS Of the 27,943 participants, the mean age was 45.10 years, with 14,018 [weighted, 50.0%] females and 11,045 [weighted, 66.0%] non-Hispanic White. After multivariable adjustment, inverse associations between PA and prescription opioid use were observed for sufficient (≥ 150 min/week) total PA (OR,0.68 95%CI [0.56-0.81]), TPA (OR,0.73 95%CI [0.58-0.92]), and LTPA (OR,0.60 95%CI [0.48-0.75]) compared with insufficient PA(< 150 min/week), but not for sufficient OPA (OR,0.93 95%CI [0.79-1.10]). In addition, the associations were dose-responsive, participants had 22-40%, 27-36%, and 26-47% lower odds of using prescription opioids depending on the duration of total PA, TPA, and LTPA, respectively. Nevertheless, the impact of PA on prescription opioid use varied by duration of opioid use. Sufficient total PA was associated with elevated odds of short-term use of prescription opioids (< 90 days). Comparatively, sufficient total PA, TPA, and LTPA had different beneficial effects on reducing long-term use of prescription opioids (≥ 90 days) depending on the strength of opioids. CONCLUSIONS This study demonstrated sufficient total PA, TPA, and LTPA were inversely associated with prescription opioid use and varied depending on the duration and strength of prescription opioid use. These findings highlight PA can provide policy guidance to address opioid crisis.
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Affiliation(s)
- Junpeng Wu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University; The Key Laboratory of Precision Anesthesia & Perioperative Organ Protection, Guangzhou North Road, Guangzhou, 510515, Guangdong, China
| | - Panpan Yang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University; The Key Laboratory of Precision Anesthesia & Perioperative Organ Protection, Guangzhou North Road, Guangzhou, 510515, Guangdong, China
| | - Xiaodan Wu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University; The Key Laboratory of Precision Anesthesia & Perioperative Organ Protection, Guangzhou North Road, Guangzhou, 510515, Guangdong, China
| | - Xiaoxuan Yu
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangdong, China
| | - Fanfang Zeng
- Department of Anesthesiology, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Guangdong, China
| | - Haitang Wang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University; The Key Laboratory of Precision Anesthesia & Perioperative Organ Protection, Guangzhou North Road, Guangzhou, 510515, Guangdong, China.
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Ruggiero E, Pambuku A, Caccese M, Lombardi G, Gallio I, Brunello A, Ceccato F, Formaglio F. Case report: The lesson from opioid withdrawal symptoms mimicking paraganglioma recurrence during opioid deprescribing in cancer pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1256809. [PMID: 37810433 PMCID: PMC10556467 DOI: 10.3389/fpain.2023.1256809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Pain is one of the predominant and troublesome symptoms that burden cancer patients during their whole disease trajectory: adequate pain management is a fundamental component of cancer care. Opioid are the cornerstone of cancer pain relief therapy and their skillful management must be owned by physicians approaching cancer pain patients. In light of the increased survival of cancer patients due to advances in therapy, deprescription should be considered as a part of the opioid prescribing regime, from therapy initiation, dose titration, and changing or adding drugs, to switching or ceasing. In clinical practice, opioid tapering after pain remission could be challenging due to withdrawal symptoms' onset. Animal models and observations in patients with opioid addiction suggested that somatic and motivational symptoms accompanying opioid withdrawal are secondary to the activation of stress-related process (mainly cortisol and catecholamines mediated). In this narrative review, we highlight how the lack of validated guidelines and tools for cancer patients can lead to a lower diagnostic awareness of opioid-related disorders, increasing the risk of developing withdrawal symptoms. We also described an experience-based approach to opioid withdrawal, starting from a case-report of a symptomatic patient with a history of metastatic pheochromocytoma-paraganglioma.
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Affiliation(s)
- Elena Ruggiero
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Ardi Pambuku
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Mario Caccese
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Ivan Gallio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Antonella Brunello
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Fabio Formaglio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
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Lin L, Lin J, Qiu J, Wei F, Bai X, Ma W, Zeng J, Lin D. Gut microbiota alterations may increase the risk of prescription opioid use, but not vice versa: A two-sample bi-directional Mendelian randomization study. Front Microbiol 2022; 13:994170. [PMID: 36483210 PMCID: PMC9722965 DOI: 10.3389/fmicb.2022.994170] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/01/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Gut microbiota alterations are strongly associated with prescription opioid use (POU) and multisite chronic pain (MCP). However, whether or not these associations are causal remains unknown. Therefore, we aim to explore the causal relationships between them comprehensively. METHODS A two-sample bi-directional Mendelian randomization was conducted to assess the potential associations between gut microbiota and POU/MCP using summary level Genome-wide association studies (GWASs) that were based on predominantly European ancestry. RESULTS Potential causal effects were identified between seven host genetic-driven traits of gut microbiota on POU, including Adlercreutzia, Allisonella, Dialister, Anaerofilum, Anaerostipes, ChristensenellaceaeR.7group, and LachnospiraceaeNC2004group at the genus level (p < 0.05) by the Inverse-variance weighted method, with significant causal effects of ChristensenellaceaeR.7group and Allisonella on POU (p < 0.025). A total of five genetically greater abundance of gut microbiota traits were identified to be possibly related to the level of MCP (p < 0.05), including genus ErysipelotrichaceaeUCG003, family Clostridiaceae1, order Gastranaerophilales, order Actinomycetales, and family Actinomycetaceae. In the other direction, no clear evidence was found to support a significant causal relationship between POU and gut microbiota, as well as MCP and gut microbiota. In addition, evidence was also provided for the relationship between triacylglycerols and diacylglycerol elevation, and an increased risk of POU and MCP. No evidence was found across various sensitivity analyses, including reverse causality, pleiotropy, and heterogeneity. CONCLUSION The findings from this study provide robust evidence that gut microbiota alterations may be a risk of POU/MCP, but not vice versa.
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Affiliation(s)
- Liling Lin
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianwei Lin
- Big Data Laboratory, Joint Shantou International Eye Center of Shantou University and The Chinese University of Hong Kong, Shantou, Guangdong, China
| | - Junxiong Qiu
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Feng Wei
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaohui Bai
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weiying Ma
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingxian Zeng
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Daowei Lin
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Bhattacharya D, Whiteside H, Tang E, Kantilal K, Loke Y, Atkins B, Hill C. A review of trial and real-world data applying elements of a realist approach to identify behavioural mechanisms supporting practitioners to taper opioids. Br J Clin Pharmacol 2022; 88:4019-4042. [PMID: 35561033 PMCID: PMC9543530 DOI: 10.1111/bcp.15379] [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: 11/28/2021] [Revised: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022] Open
Abstract
This evidence synthesis applying realist concepts and behavioural science aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid‐tapering interventions and services from a 2018 international systematic review and a 2019 England‐wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid‐tapering success. A stakeholder group (n = 23) generated draft programme theories based around the 14 domains of the Theoretical Domains Framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified 6 programme theories comprising 5 behavioural mechanisms: prescribers' knowledge about how to taper; build prescribers' beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all 6 mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive‐based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.
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Affiliation(s)
- Debi Bhattacharya
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | | | - Emma Tang
- School of Pharmacy, University of East Anglia, Norwich, UK
| | - Kumud Kantilal
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Bethany Atkins
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | - Caroline Hill
- School of Pharmacy, University of East Anglia, Norwich, UK
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Magee M, Gholamrezaei A, McNeilage AG, Dwyer L, Sim A, Ferreira M, Darnall B, Glare P, Ashton-James C. Evaluating acceptability and feasibility of a mobile health intervention to improve self-efficacy in prescription opioid tapering in patients with chronic pain: protocol for a pilot randomised, single-blind, controlled trial. BMJ Open 2022; 12:e057174. [PMID: 35473742 PMCID: PMC9045093 DOI: 10.1136/bmjopen-2021-057174] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Opioid medications are no longer recommended as long-term therapy for chronic non-cancer pain, and many patients are advised to reduce or discontinue opioid medications. Many patients report difficulties in tapering opioid medications, necessitating supporting interventions. This protocol describes a pilot randomised controlled trial (RCT) to investigate the acceptability, feasibility and potential efficacy of a mobile health intervention to improve the opioid tapering self-efficacy of patients with chronic non-cancer pain. METHODS AND ANALYSIS The trial will be a single-blind (clinician, data collector and statistician-blinded) pilot RCT with two parallel arms. Forty adult patients with chronic non-cancer pain who are voluntarily reducing their prescribed opioid medications under medical guidance will be recruited from two tertiary pain clinics (Start date 25 August 2021). Participants will be randomly assigned to an intervention or control group. Both groups will receive usual care, including multidisciplinary pain management. In addition to usual care, the intervention group will receive a short informational and testimonial video about opioid tapering and will receive two specifically text messages per day for 28 days. The intervention is codesigned with patients and clinicians to provide evidence-based informational, motivational and emotional support to patients with chronic pain to taper opioid medications. Feasibility of the intervention and a future definitive RCT will be evaluated by measuring patient acceptability, delivery of the intervention, rates and reasons of exclusions and drop-outs, completion rates and missing data in the study questionnaires, and obtaining estimates for sample size determination. Potential efficacy will be evaluated by comparing changes in opioid tapering self-efficacy between the two groups. ETHICS AND DISSEMINATION The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings. TRIAL REGISTRATION NUMBER ACTRN12621000795897.
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Affiliation(s)
- Michael Magee
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Amy Gray McNeilage
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Leah Dwyer
- Consumer Advisory Group, Painaustralia, Deakin, Victoria, Australia
| | - Alison Sim
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela Ferreira
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
- School of Health Sciences, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Beth Darnall
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Paul Glare
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
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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] [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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Langejan AI, de Kleijn L, Rijkels-Otters HJBM, Chudy SFJ, Chiarotto A, Koes BW. Effectiveness of non-opioid interventions to reduce opioid withdrawal symptoms in patients with chronic pain: a systematic review. Fam Pract 2022; 39:295-300. [PMID: 34849764 PMCID: PMC9030234 DOI: 10.1093/fampra/cmab159] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dealing with the opioid crisis, medical doctors are keen to learn how to best treat opioid dependency in patients with chronic non-cancer pain. Opioid replacement therapy is commonly used, but success rates vary widely. Since many patients still experience severe withdrawal symptoms, additional interventions are necessary. OBJECTIVE To review the effectiveness of interventions in the treatment of withdrawal symptoms during opioid tapering or acute withdrawal in patients with long-term non-cancer pain. METHODS A systematic review was conducted in Embase.com, MEDLINE, Web of Science, PsycINFO, and Cochrane CENTRAL register of trials. Studies eligible for inclusion were (non-)randomized controlled trials in adults with long-term opioid prescriptions for non-cancer pain. Included trials had to compare a non-opioid intervention to placebo, usual care, no treatment, or non-opioid drug and had to report on withdrawal symptoms as an outcome. Study quality was assessed with the 2.0 Cochrane risk of bias (RoB) tool. Evidence quality was rated following the GRADE approach. RESULTS One trial (n = 21, some concerns regarding RoB) compared Varenicline to placebo. There was no statistically significant between-group reduction of withdrawal symptoms (moderate-quality evidence). CONCLUSIONS Evidence from clinical trials on interventions reducing withdrawal symptoms is scarce. Based on one trial with a small sample size, no firm conclusion can be drawn. Meanwhile, doctors are in dire need for therapeutic options to tackle withdrawal symptoms while tapering patients with prescription opioid dependence. We hope this review draws attention to this unfortunate research gap so that future research can provide doctors with answers.
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Affiliation(s)
- Annely I Langejan
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Loes de Kleijn
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Stan F J Chudy
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Sandhu HK, Shaw J, Carnes D, Furlan AD, Tysall C, Adjei H, Muthiah C, Noyes J, Tang NKY, Taylor SJ, Underwood M, Willis A, Eldabe S. Development and testing of an opioid tapering self-management intervention for chronic pain: I-WOTCH. BMJ Open 2022; 12:e053725. [PMID: 35296478 PMCID: PMC8928279 DOI: 10.1136/bmjopen-2021-053725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To describe the design, development and pilot of a multicomponent intervention aimed at supporting withdrawal of opioids for people with chronic non-malignant pain for future evaluation in the Improving the Wellbeing of people with Opioid Treated CHronic pain (I-WOTCH) randomised controlled trial. DESIGN The I-WOTCH intervention draws on previous literature and collaboration with stakeholders (patient and public involvement). Intervention mapping and development activities of Behaviour Change Taxonomy are described. SETTING The intervention development was conducted by a multidisciplinary team with clinical, academic and service user perspectives. The team had expertise in the development and testing of complex health behaviour interventions, opioid tapering and pain management in primary and secondary care, I.T programming, and software development-to develop an opioid tapering App. PARTICIPANTS The I-WOTCH trial participants are adults (18 years and over) with chronic non-malignant pain using strong opioids for at least 3 months and on most days in the preceding month. OUTCOMES A multicomponent self-management support package to help people using opioids for chronic non-malignant pain reduce opioid use. INTERVENTIONS AND RESULTS Receiving information on the impact of long-term opioid use, and potential adverse effects were highlighted as important facilitators in making the decision to reduce opioids. Case studies of those who have successfully stopped taking opioids were also favoured as a facilitator to reduce opioid use. Barriers included the need for a 'trade-off to fill the deficit of the effect of the drug'. The final I-WOTCH intervention consists of an 8-10 week programme incorporating: education; problem-solving; motivation; group and one to one tailored planning; reflection and monitoring. A detailed facilitator manual was developed to promote consistent delivery of the intervention across the UK. CONCLUSIONS We describe the development of an opioid reduction intervention package suitable for testing in the I-WOTCH randomised controlled trial. TRIAL REGISTRATION NUMBER ISRCTN49470934.
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Affiliation(s)
- Harbinder Kaur Sandhu
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jane Shaw
- Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Dawn Carnes
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Andrea D Furlan
- Toronto Rehabilitation Institute, University Health Network, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Institute for Work & Health, Toronto, Ontario, Canada
| | - Colin Tysall
- UNTRAP, University of Warwick, Coventry, West Midlands, UK
- SUCE, Coventry University, Coventry, West Midlands, UK
| | - Henry Adjei
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chockalingam Muthiah
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jennifer Noyes
- Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Nicole K Y Tang
- Department of Psychology, University of Warwick, Coventry, West Midlands, UK
| | - Stephanie Jc Taylor
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Adrian Willis
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sam Eldabe
- Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
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Wiens M, Jarrett D, Settimi A, White C, Hollingham Z, Packham T. Role of Rehabilitation in Opioid Tapering: A Scoping Review. Physiother Can 2022; 74:75-85. [PMID: 35185251 PMCID: PMC8816366 DOI: 10.3138/ptc-2020-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 10/13/2020] [Accepted: 10/19/2020] [Indexed: 01/03/2023]
Abstract
Purpose: Among industrialized countries, Canada has the second-highest opioid prescribing rate for pain management. Physiotherapy and occupational therapy interventions are potential non-pharmacological alternatives. We undertook a scoping review to explore and summarize the current evidence describing the interventions included or used in physiotherapy and occupational therapy in opioid tapering for individuals with chronic pain. Method: A systematic search of the peer-reviewed health databases was conducted, with data synthesis guided by Arksey and O'Malley's scoping review methodology. Articles were included in the narrative synthesis if (1) interventions within the scope of practice for physiotherapists or occupational therapists were described or these professionals were part of interdisciplinary care and (2) opioid tapering or reduction was addressed. Results: The 39 articles identified included 2 systematic reviews, 9 narrative reviews or commentaries, 2 case reports, 11 uncontrolled cohort studies, 1 cross-sectional study, 5 randomized controlled trials, 4 programme evaluations, and 4 qualitative studies. Of the 28 studies reporting specific outcomes, 25 reported positive outcomes of rehabilitation interventions for opioid tapering. There was greater representation of interventions from physiotherapy than from occupational therapy: few articles contained substantive descriptions (e.g., dosage and duration). Conclusions: The evidence to guide therapists in supporting opioid tapering for people with chronic pain seems to be limited. Further research is needed to establish effectiveness for stand-alone interventions and as part of a comprehensive rehabilitation approach.
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Affiliation(s)
- Miranda Wiens
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Devon Jarrett
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Alissa Settimi
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Courtney White
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Zachary Hollingham
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Tara Packham
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
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10
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A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews. Int J Clin Pharm 2021; 44:235-246. [PMID: 34751891 DOI: 10.1007/s11096-021-01340-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.
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11
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Fishbain DA. Opioid Tapering/Detoxification Protocols, A Compendium: Narrative Review. PAIN MEDICINE 2021; 22:1676-1697. [PMID: 33860319 DOI: 10.1093/pm/pnab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The opioid epidemic has put pressure on clinicians to taper their chronic pain patients (CPPs) from opioids. This has resulted in rapid or forced tapers and opioid discontinuation. Partially responsible is lack of information on how to taper (tapering protocols).The objectives of this narrative review were then the following: compile all the published opioid tapering/detoxification protocols from the pain/drug rehabilitation/psychiatric literature whether for inpatient or outpatient use; organize these into general types; compare the types for advantages/disadvantages for use by a clinician in an outpatient setting; and answer some commonly asked questions relating to opioid tapering. METHODS Relevant references were identified by a search strategy utilizing the terms tapering, tapering protocols, detoxification, detoxification protocols, withdrawal, dependence, addiction, and drug rehabilitation. These were explored with the term opioids. Identified abstract were reviewed for any study relating to the objectives of this review. Those studies were then included in this review. As this is a narrative review, no quality ratings of these references were performed. RESULTS Of 1,922 abstracts identified by this search strategy, 301 were reviewed in detail for potential inclusion. Of these, 104 were utilized in this review. Nine types of opioid tapering protocols were identified and compared in tabular form. Twenty-two questions in reference to opioid tapering were addressed. CONCLUSIONS Based on this review, the protocol utilizing the opioid of current use is the simplest to use as it requires no rotation to another opioid and thereby avoids rotation errors. It also has behavior advantages.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Neurological Surgery, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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12
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Quah MCH, Marney BC, Cooper RJ, Dickson JM. Chronic pain and opioid analgesic use: A case report. Clin Case Rep 2021; 9:e04370. [PMID: 34257976 PMCID: PMC8259929 DOI: 10.1002/ccr3.4370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/23/2020] [Accepted: 05/07/2021] [Indexed: 11/11/2022] Open
Abstract
Relationship-based medical care is essential in the management of chronic pain. Opioids are often ineffective and can cause significant harm. However, there is significant time pressure, and there are insufficient resources and guidelines for GPs to be able to offer alternatives, putting the NHS at risk of a growing opioid epidemic.
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Affiliation(s)
| | | | - Richard J. Cooper
- School of Health And Related Research (ScHARR)University of SheffieldSheffieldUK
| | - Jon M. Dickson
- The Medical SchoolThe University of SheffieldSheffieldUK
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13
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Magee MR, McNeilage AG, Avery N, Glare P, Ashton-James CE. mHealth Interventions to Support Prescription Opioid Tapering in Patients With Chronic Pain: Qualitative Study of Patients' Perspectives. JMIR Form Res 2021; 5:e25969. [PMID: 34003133 PMCID: PMC8170552 DOI: 10.2196/25969] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/29/2021] [Accepted: 04/06/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with chronic pain who are tapering prescription opioids report a need for greater support for coping with symptoms of pain and withdrawal. Mobile health (mHealth) technologies (SMS text messaging- or app-based) have the potential to provide patients with educational, emotional, and motivational support for opioid tapering beyond what is offered by their health care provider. However, it is not known whether patients with chronic pain who are tapering opioids would be willing or able to engage with technology-based support. OBJECTIVE This study aims to examine patients' use of mobile technologies in health care, interest in using mHealth support, preferences for the form and content of mHealth support, and potential barriers to and facilitators of engagement with mHealth support for opioid tapering. METHODS A total of 21 patients (11 women and 10 men; age range 29-83 years) with chronic noncancer pain on long-term opioid therapy who had recently initiated a voluntary opioid taper were recruited from primary and tertiary care clinics in metropolitan and regional Australia for a larger study of patients' experiences of opioid tapering. Participants had been taking prescription opioids for a mean duration of 13 (SD 9.6; range 0.25-30) years at the time of the study. Survey items characterized participants' typical mobile phone use and level of interest in mobile technology-based support for opioid tapering. Semistructured interviews further explored patients' use of mobile technologies and their interest in, preferences for, and perspectives on potential barriers to and facilitators of engagement with mHealth support for opioid tapering. Two researchers collaborated to conduct a thematic analysis of the interview data. RESULTS All participants reported owning and using a mobile phone, and most (17/21, 81%) participants reported using mobile apps. The majority of participants expressed interest in SMS text messaging-based (17/21, 81%) and app-based (15/21, 71%) support for opioid tapering. Participants expected that messages delivering both informational and socioemotional support would be helpful. Participants expected that access to technology, mobile reception, internet connectivity, vision impairment, and low self-efficacy for using apps may be barriers to user engagement. Patients expected that continuity of care from their health care provider, flexible message dosing, responsivity, and familiarity with pain self-management strategies would increase user engagement. CONCLUSIONS The results of this study indicate that patients with chronic noncancer pain may be willing to engage with SMS text messaging-based and app-based mHealth interventions to support opioid tapering. However, the feasibility and acceptability of these interventions may depend on how patients' preferences for functionality, content, and design are addressed.
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Affiliation(s)
- Michael Reece Magee
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Amy Gray McNeilage
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Nicholas Avery
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Paul Glare
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Claire Elizabeth Ashton-James
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
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14
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Wakaizumi K, Vigotsky AD, Jabakhanji R, Abdallah M, Barroso J, Schnitzer TJ, Apkarian AV, Baliki MN. Psychosocial, Functional, and Emotional Correlates of Long-Term Opioid Use in Patients with Chronic Back Pain: A Cross-Sectional Case-Control Study. Pain Ther 2021; 10:691-709. [PMID: 33844170 PMCID: PMC8119524 DOI: 10.1007/s40122-021-00257-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/13/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The opiate epidemic has severe medical and social consequences. Opioids are commonly prescribed in patients with chronic pain, and are a main contributor to the opiate epidemic. The adverse effects of long-term opioid usage have been studied primarily in dependence/addiction disorders, but not in chronic pain. Here, we examine the added iatrogenic effects, psychology, and brain morphology of long-term opioid use in matched patients with chronic pain with and without opioid use (case-controlled design). METHODS We compared psychosocial, functional, and psychological measures between patients with chronic back pain (CBP) who were managing their pain with or without opioids, thereby controlling for the effect of pain on these outcomes. In addition, we investigated brain morphological differences associated with long-term opioid usage. We recruited 58 patients with CBP, 29 of them on long-term opioids and 29 who did not use opioids, and who were matched in terms of age, sex, pain intensity, and pain duration. Questionnaires were used to assess pain quality, pain psychology, negative and positive emotions, physical, cognitive, sensory, and motor functions, quality of life, and personality traits. RESULTS Patients with CBP on opioids displayed more negative emotion, poorer physical function, and more pain interference (p < 0.001), whereas there were no statistical differences in cognitive and motor functions and personality traits. Voxel-based morphometry using structural brain imaging data identified decreased gray matter density of the dorsal paracingulate cortex (family-wise error-corrected p < 0.05) in patients with opioids, which was associated with negative emotion (p = 0.03). Finally, a volumetric analysis of hippocampal subfields identified lower volume of the left presubiculum in patients on opioids (p < 0.001). CONCLUSION Long-term opioid use in chronic pain is associated with adverse negative emotion and disabilities, as well as decreased gray matter volumes of specific brain regions.
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Affiliation(s)
- Kenta Wakaizumi
- Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, 355 East Erie St, Chicago, IL, 60611, USA.,Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA.,Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Andrew D Vigotsky
- Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA.,Department of Statistics, Northwestern University, Evanston, IL, USA
| | - Rami Jabakhanji
- Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, 355 East Erie St, Chicago, IL, 60611, USA.,Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Maryam Abdallah
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, 355 East Erie St, Chicago, IL, 60611, USA.,Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Joana Barroso
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, 355 East Erie St, Chicago, IL, 60611, USA.,Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Thomas J Schnitzer
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, 355 East Erie St, Chicago, IL, 60611, USA.,Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Apkar Vania Apkarian
- Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA. .,Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, USA. .,Department of Anesthesia, Feinberg School of Medicine, Northwestern University, Tarry Bldg. 7-705, Chicago, IL, 60611, USA.
| | - Marwan N Baliki
- Shirley Ryan AbilityLab, Chicago, IL, USA. .,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, 355 East Erie St, Chicago, IL, 60611, USA. .,Center for Translational Pain Research, and Center of Excellence for Chronic Pain and Drug Abuse Research, Northwestern University Feinberg School of Medicine, Chicago, USA.
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15
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White R, Bruggink L, Hayes C, Boyes A, Paul C. Feasibility of patient-focused behavioral interventions to support adults experiencing chronic noncancer pain during opioid tapering: a systematic literature review. Transl Behav Med 2021; 11:1481-1494. [PMID: 33677606 DOI: 10.1093/tbm/ibab007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Guidelines for chronic noncancer pain prioritize behavioral treatments. In clinical practice transition from opioids to behavioral treatments is often not endorsed by patients or providers. Feasible interventions to support opioid tapering are needed, particularly in primary care. The objectives of this paper is to review the feasibility of behavioral interventions to support opioid tapering. Electronic databases (MEDLINE, Embase, PsycINFO, and CINAHL) were searched from inception to June 2019 to identify original studies reporting feasibility (consent rates; completion rates; patient-reported acceptability; integration into clinical practice; and adverse events) of opioid tapering and transition to behavioral treatments for adults experiencing chronic noncancer pain. Google scholar and contents tables of key journals were also searched. Two authors independently extracted data and assessed methodological quality using The Quality Assessment Tool for Quantitative Studies. Eleven publications met inclusion criteria, of which three were conducted in primary care. Consent rates ranged from 27% to 98% and completion rates from 6.6% to 100%. Four studies rated at least one component of patient acceptability: helpfulness from 50%-81%; satisfaction 71%-94%, and "recommend to others" 74%-91%. Three studies reported provider perspectives and two studies reported adverse events. Quality assessment indicated all 11 studies were moderate or weak, primarily due to selection bias and lack of assessor blinding. There was also considerable heterogeneity in study design. The limited available data suggest that attempts to translate opioid tapering interventions into practice are likely to encounter substantial feasibility challenges. One possible way to ameliorate this challenge may be a clear policy context, which facilitates and support opioid reduction.
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Affiliation(s)
- Ruth White
- Hunter Integrated Pain Service
- Surgical Services, John Hunter Hospital, Newcastle, NSW, Australia
| | - Laura Bruggink
- Hunter Integrated Pain Service
- Surgical Services, John Hunter Hospital, Newcastle, NSW, Australia
| | - Chris Hayes
- Hunter Integrated Pain Service
- Surgical Services, John Hunter Hospital, Newcastle, NSW, Australia
| | - Allison Boyes
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Public Health Program, Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Chris Paul
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
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16
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Affiliation(s)
- Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Colin Tysall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
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17
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Binswanger IA, Glanz JM, Faul M, Shoup JA, Quintana LM, Lyden J, Xu S, Narwaney KJ. The Association between Opioid Discontinuation and Heroin Use: A Nested Case-Control Study. Drug Alcohol Depend 2020; 217:108248. [PMID: 32927194 PMCID: PMC10959283 DOI: 10.1016/j.drugalcdep.2020.108248] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Opioid prescribing guidelines recommend reducing or discontinuing opioids for chronic pain if harms of opioid treatment outweigh benefits. As opioid discontinuation becomes more prevalent, it is important to understand whether opioid discontinuation is associated with heroin use. In this study, we sought to assess the association between opioid discontinuation and heroin use documented in the medical record. METHODS A matched nested case-control study was conducted in an integrated health plan and delivery system in Colorado. Patients receiving opioid therapy in the study period (January 2006-June 2018) were included. Opioid discontinuation was defined as ≥45 days with no opioids dispensed after initiating opioid therapy. The heroin use onset date represented the index date. Case patients were matched to up to 20 randomly selected patients without heroin use (control patients) by age, sex, calendar time, and time between initiating opioid therapy and the index date. Conditional logistic regression models estimated matched odds ratios (mOR) for the association between an opioid discontinuation prior to the index date and heroin use. RESULTS Among 22,962 patients prescribed opioid therapy, 125 patients (0.54%) used heroin after initiating opioid therapy, of which 74 met criteria for inclusion in the analysis. The odds of opioid discontinuation were approximately two times higher in case patients (n = 74) than control patients (n = 1045; mOR = 2.19; 95% CI 1.27-3.78). CONCLUSIONS Among patients prescribed chronic opioid therapy, the observed increased risk for heroin use associated with opioid discontinuation should be balanced with potential benefits.
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Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado Permanente Medical Group, Aurora, CO; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado School of Public Health, Aurora, CO
| | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - LeeAnn M Quintana
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jennifer Lyden
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Denver Health, Department of Medicine, Denver, CO
| | - Stan Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
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18
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Manchira Krishnan S, Gc VS, Sandhu HK, Underwood M, Eldabe S, Manca A, Iglesias Urrutia CP. Protocol for an economic analysis of the randomised controlled trial of Improving the Well-being of people with Opioid Treated CHronic pain: I-WOTCH Study. BMJ Open 2020; 10:e037243. [PMID: 33444175 PMCID: PMC7682467 DOI: 10.1136/bmjopen-2020-037243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Over the last two decades, the use of opioids for the treatment of chronic pain in England has steadily increased despite lack of evidence of both long-term effectiveness in pain relief and significant, well-documented physical and mental adverse events. Guidelines recommend tapering when harms outweigh benefits, but the addictive nature of opioids hinders simple dose-reduction strategies. Improving the Well-being of people with Opioid Treated CHronic pain (I-WOTCH) trial tests a multicomponent self-management intervention aimed to help patients with chronic non-malignant pain taper opioid doses. This paper outlines the methods to be used for the economic analysis of the I-WOTCH intervention compared with the best usual care. METHODS AND ANALYSIS Economic evaluation alongside the I-WOTCH study, prospectively designed to identify, measure and value key healthcare resource use and outcomes arising from the treatment strategies being compared. A within-trial cost-consequences analysis and a model-based long-term cost-effectiveness analysis will be conducted from the National Health Service and Personal Social Service perspective in England. The former will quantify key parameters to populate a Markov model designed to estimate the long-term cost and quality-adjusted life years of the I-WOTCH intervention against best usual care. Regression equations will be used to estimate parameters such as transition probabilities, utilities, and costs associated with the model's states and events. Probabilistic sensitivity analysis will be used to assess the impact of parameter uncertainty onto the predicted costs and health outcomes, and the resulting value for money assessment of the I-WOTCH intervention. ETHICS AND DISSEMINATION Full ethics approval was granted by Yorkshire & The Humber-South Yorkshire Research Ethics Committee on 13 September 2016 (16/YH/0325). Current protocol: V.1.7, date 31 July 2019. Findings will be disseminated in peer-reviewed journals, scientific conferences, newsletters and websites. TRIAL REGISTRATION NUMBER International Standard Randomised Controlled Trial Number (49 470 934); Pre-result.
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Affiliation(s)
| | - Vijay Singh Gc
- Centre for Health Economics, University of York, York, UK
| | - Harbinder Kaur Sandhu
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Sam Eldabe
- Pain Department, James Cook University Hospital, Middlesbrough, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | - Cynthia P Iglesias Urrutia
- Department of Health Sciences, University of York, York, UK
- Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
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19
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Thorlund JB, Roos EM, Goro P, Ljungcrantz EG, Grønne DT, Skou ST. Patients use fewer analgesics following supervised exercise therapy and patient education: an observational study of 16 499 patients with knee or hip osteoarthritis. Br J Sports Med 2020; 55:670-675. [PMID: 32958468 DOI: 10.1136/bjsports-2019-101265] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate changes in analgesic use before and after supervised exercise therapy and patient education in patients with knee or hip osteoarthritis (OA). METHODS We recruited 16 499 of 25 933 eligible patients (64%; mean age 64.9; SD 9.6; 73% women) from the Good Life with osteoArthritis in Denmark (GLA:D) registry. Change in proportions of analgesic users (categorised according to analgesic risk profile; opioids > non-steroidal anti-inflammatory drugs > paracetamol) was assessed from before to after an 8-week supervised exercise therapy and patient education programme targeting knee or hip OA pain and functional limitations. RESULTS Patients reported 13.2 mm (95% CI 12.8 to 13.6) less pain (visual analogue scale 0-100 mm) at follow-up compared with baseline. The proportion of analgesic users reduced from 62.2% (95% CI 61.5 to 63.0) at baseline to 44.1% (95% CI 43.3 to 44.9) at follow-up (absolute change: 18.1% (95% CI 17.3 to 19.0)). Among patients using analgesics at baseline, 52% changed to a lower risk analgesic or discontinued analgesic use. The proportion of opioid users after the exercise therapy was 2.5% (95% CI 2.1 to 2.9) lower than baseline; this represents a relative reduction of 36%. CONCLUSION Among patients with knee or hip OA using analgesics, more than half either discontinued analgesic use or shifted to lower risk analgesics following an 8-week structured exercise therapy and patient education programme (GLA:D). These data encourage randomised controlled trial evaluation of whether supervised exercise therapy, combined with patient education, can reduce analgesic use, including opioids, among patients with knee and hip OA pain.
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Affiliation(s)
- Jonas Bloch Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark .,Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Patricia Goro
- School of Medicine, Örebro University, Örebro, Sweden
| | | | - Dorte Thalund Grønne
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Søren T Skou
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
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20
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RIch R, Chou R, Mariano ER, Legreid Dopp A, Sullenger R, Burstin H. Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings. NAM Perspect 2020; 2020:202008c. [DOI: 10.31478/202008c] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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21
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Sturgeon JA, Sullivan MD, Parker-Shames S, Tauben D, Coelho P. Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis. PAIN MEDICINE 2020; 21:3635-3644. [DOI: 10.1093/pm/pnaa029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Background
There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently, there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use.
Methods
The current study details a retrospective review of 240 patients with chronic pain and LTOT presenting for treatment at a specialty opioid refill clinic. Patients first were initiated on an outpatient taper or, if taper was not tolerated, transitioned to buprenorphine. This study analyzes potential predictors of successful tapering, successful buprenorphine transition, or failure to complete either intervention and the effects of this clinical approach on pain intensity scores.
Results
One hundred seven patients (44.6%) successfully tapered their opioid medications under the Centers for Disease Control and Prevention guideline target dose (90 mg morphine-equianalgesic dosage), 45 patients (18.8%) were successfully transitioned to buprenorphine, and 88 patients (36.6%) dropped out of treatment: 11 patients during taper, eight during buprenorphine transition, and 69 before initiating either treatment. Conclusions. Higher initial doses of opioids predicted a higher likelihood of requiring buprenorphine transition, and a co-occurring benzodiazepine or z-drug prescription predicted a greater likelihood of dropout from both interventions. Patterns of change in pain intensity according to treatment were mixed: among successfully tapered patients, 52.8% reported greater pain and 23.6% reported reduced pain, whereas 41.8% reported increased pain intensity and 48.8% reported decreased pain after buprenorphine transition. Further research is needed on predictors of treatment retention and dropout, as well as factors that may mitigate elevated pain scores after reduction of opioid dosing.
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Affiliation(s)
- John A Sturgeon
- Department of Anesthesiology and Pain Medicine, University of Washington Medical School, Seattle, Washington
| | - Mark D Sullivan
- Department of Anesthesiology and Pain Medicine, University of Washington Medical School, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Seattle, Washington
| | | | - David Tauben
- Department of Anesthesiology and Pain Medicine, University of Washington Medical School, Seattle, Washington
| | - Paul Coelho
- Department of Physical Medicine and Rehabilitation/Pain Medicine, Salem Health Pain Clinic, Salem, Oregon, USA
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22
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Shadbolt C, Abbott JH, Camacho X, Clarke P, Lohmander LS, Spelman T, Sun EC, Thorlund JB, Zhang Y, Dowsey MM, Choong PFM. The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action. Front Surg 2020; 7:4. [PMID: 32133370 PMCID: PMC7041404 DOI: 10.3389/fsurg.2020.00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/29/2020] [Indexed: 12/27/2022] Open
Abstract
Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.
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Affiliation(s)
- Cade Shadbolt
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ximena Camacho
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia
| | - Philip Clarke
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Tim Spelman
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Rigshospitalet, Copenhagen, Denmark
| | - Eric C Sun
- Department of Anaesthesiology, Perioperative and Pain Medicine and Department of Health Research and Policy, Stanford University, Stanford, CA, United States
| | - Jonas B Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Yuting Zhang
- Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, University of Melbourne, Carlton, VIC, Australia
| | - Michelle M Dowsey
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Peter F M Choong
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
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23
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Safer DJ. Overprescribed Medications for US Adults: Four Major Examples. J Clin Med Res 2019; 11:617-622. [PMID: 31523334 PMCID: PMC6731049 DOI: 10.14740/jocmr3906] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/15/2019] [Indexed: 12/24/2022] Open
Abstract
To understand possible medication overprescribing, it would be important to know which classes are the most prescribed, for which indications, for what duration, and for which age groups. Among the 10 most frequently prescribed medication classes for US adults, four were evaluated for overprescribing, and systematically assessed in relation to their primary indication. The assessment included usage patterns, trends, age of recipients, treatment duration, and benefits versus adverse consequences. The findings in this selective review are supported by an extensive search of the medical literature. The four selected medication categories and their most common indication included opioids for chronic pain, proton pump inhibitors for indigestion, levothyroxine for subclinical hypothyroidism, and antidepressants for subsyndromal levels of depression. These medications, grouped by their most frequent indication along with polypharmacy, have experienced major prescription increases in recent years, particularly among older patients. Most concerning is that they have been frequently prescribed for extended periods, usually with inadequate evidence of benefit. High drug usage patterns can aid in quantifying overprescribing within polypharmacy by age group.
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Affiliation(s)
- Daniel J Safer
- Departments of Psychiatry and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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24
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Sandhu HK, Abraham C, Alleyne S, Balasubramanian S, Betteley L, Booth K, Carnes D, Furlan AD, Haywood K, Iglesias Urrutia CP, Lall R, Manca A, Mistry D, Nichols VP, Noyes J, Rahman A, Seers K, Shaw J, Tang NKY, Taylor S, Tysall C, Underwood M, Withers EJ, Eldabe S. Testing a support programme for opioid reduction for people with chronic non-malignant pain: the I-WOTCH randomised controlled trial protocol. BMJ Open 2019; 9:e028937. [PMID: 31399456 PMCID: PMC6701652 DOI: 10.1136/bmjopen-2019-028937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Chronic non-malignant pain has a major impact on the well-being, mood and productivity of those affected. Opioids are increasingly prescribed to manage this type of pain, but with a risk of other disabling symptoms, when their effectiveness has been questioned. This trial is designed to implement and evaluate a patient-centred intervention targeting withdrawal of strong opioids in people with chronic pain. METHODS AND ANALYSIS A pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of a group-based multicomponent intervention combined with individualised clinical facilitator led support for the management of chronic non-malignant pain against the control intervention (self-help booklet and relaxation compact disc). An embedded process evaluation will examine fidelity of delivery and investigate experiences of the intervention. The two primary outcomes are activities of daily living (measured by Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (8A)) and opioid use. The secondary outcomes are pain severity, quality of life, sleep quality, self-efficacy, adverse events and National Health Service (NHS) healthcare resource use. Participants are followed up at 4, 8 and 12 months, with a primary endpoint of 12 months. Between-group differences will indicate effectiveness; we are looking for a difference of 3.5 points on our pain interference outcome (scale 40 to 77). We will undertake an NHS perspective cost-effectiveness analysis using quality adjusted life years. ETHICS AND DISSEMINATION Full approval was given by Yorkshire & The Humber - South Yorkshire Research Ethics Committee on 13 September, 2016 (16/YH/0325). Appropriate local approvals were sought for each area in which recruitment was undertaken. The current protocol version is 1.6 date 19 December 2018. Publication of results in peer- reviewed journals will inform the scientific and clinical community. We will disseminate results to patient participants and study facilitators in a study newsletter as well as a lay summary of results on the study website. TRIAL REGISTRATION NUMBER ISRCTN49470934; Pre-results.
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Affiliation(s)
- Harbinder K Sandhu
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Abraham
- School of Psychological Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Sharisse Alleyne
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Shyam Balasubramanian
- Department of Anaesthesia and Pain Medicine, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Lauren Betteley
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Katie Booth
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Dawn Carnes
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Andrea D Furlan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Kirstie Haywood
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Vivien P Nichols
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jennifer Noyes
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Anisur Rahman
- Centre for Rheumatology Research, University College London, London, UK
| | - Kate Seers
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jane Shaw
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Nicole K Y Tang
- Department of Psychology, University of Warwick, Coventry, UK
| | - Stephanie Taylor
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Colin Tysall
- University/User Teaching and Research Action Partnership, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Emma J Withers
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
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25
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Absence of evidence to guide opioid reduction in chronic pain. Drug Ther Bull 2019; 57:101. [PMID: 31171570 DOI: 10.1136/dtb.2019.000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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26
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27
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Dose reduction of long-term opioids: our duty as clinicians. Br J Gen Pract 2019; 69:191. [DOI: 10.3399/bjgp19x701957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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