Chronic Noncancer Pain Rehabilitation With Opioid Withdrawal: Comparison of Treatment Outcomes Based on Opioid Use Status at Admission

Psychiatric and Psychological Perspectives on Chronic Pain

“…Following treatment, most of these patients report significantly reduced pain concurrent with elimination of opioid medication. [43][44][45] Portenoy 46 and others have argued forcefully that chronic opioid therapy can be appropriate and beneficial in some patients with chronic noncancer pain. One of the current, unanswered questions is what factors characterize those patients who are likely to benefit from long-term opioids without problems of addiction, tolerance, or increased disability.…”

Tapering Long-term Opioid Therapy in Chronic Noncancer Pain

“…39 The Mayo Clinic Program uses a gradual, structured taper on a time-contingent basis during 3 weeks, with rates of completion that can be above 90%. 42,54,72,73 When open-label dose reduction controlled by patients (N¼63) was compared with a masked dose reduction controlled by study staff (N¼45), patients in the blinded group were more likely to not be taking opioids (89% vs 68.3%) at the 4-week outcome, but there were no significant differences in the proportion of patients not taking medication (55% in both groups) at 6 months. 40 However, nonrandom treatment attribution and baseline differences between groups may have biased outcomes.…”

“…One program reports 78% abstinence at 6 month follow-up 42 and another one the same percentage at 12 months. 55 Studies of interdisciplinary programs found no differences in improvement in matters of psychological functioning, physical activity, or return to work between patients with and without opioids before the treatment, 42,71,73 even if these medications were not tapered. 92 This literature can be interpreted in favor of opioid tapering (patients improve after the program, despite less medication) or against it (patients improve despite continuing to take opioids).…”

“…To date, there is strong evidence supporting CBT and interdisciplinary approaches in patients with chronic pain, 85,86 moderate evidence for patients with OUD, 84 and low evidence specifically for taper support from long-term opioid treatment in CNCP. 39,40,[42][43][44]46,[71][72][73]89,91 However, considering the risks factors for dropout and adverse functional outcomes in these patients, as reviewed above, psychological support may be needed to address possible anxiety related to the taper, underlying depression, deficient pain-and stress-coping strategies (recommendation GRADE C). Simply removing a patient's main strategy for dealing with pain and perhaps mood (ie, their opioids) is unlikely to be well tolerated or allow for increased function if learning of adaptive coping mechanisms and treatment of any underlying negative affect are not encouraged.…”

“…The active treatment phases span approximately 1 month, on an inpatient 40,71 or outpatient basis, such as the Mayo Clinic Pain Rehabilitation program. [42][43][44]46,72,73 A recent systematic review of the body of literature studying CBT and interdisciplinary programs for patients with CNCP tapering from long-term opioid treatment pointed out its limitations 88 : only 2 studies are randomized clinical trials, both with small sample sizes or methodological issues. 89,90 Therefore, the authors of the review renounced drawing conclusions regarding the effectiveness of psychological, alternative, or interdisciplinary interventions to support patients tapering from opioids.…”