Reducing Opioid Use for Chronic Pain With a Group-Based Intervention

Abstract

ImportanceOpioid use for chronic nonmalignant pain can be harmful.ObjectiveTo test whether a multicomponent, group-based, self-management intervention reduced opioid use and improved pain-related disability compared with usual care.Design, Setting, and ParticipantsMulticentered, randomized clinical trial of 608 adults taking strong opioids (buprenorphine, dipipanone, morphine, diamorphine, fentanyl, hydromorphone, methadone, oxycodone, papaveretum, pentazocine, pethidine, tapentadol, and tramadol) to treat chronic nonmalignant pain. The study was conducted in 191 primary care centers in England between May 17, 2017, and January 30, 2019. Final follow-up occurred March 18, 2020.InterventionParticipants were randomized 1:1 to either usual care or 3-day–long group sessions that emphasized skill-based learning and education, supplemented by 1-on-1 support delivered by a nurse and lay person for 12 months.Main Outcomes and MeasuresThe 2 primary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference Short Form 8a (PROMIS-PI-SF-8a) score (T-score range, 40.7-77; 77 indicates worst pain interference; minimal clinically important difference, 3.5) and the proportion of participants who discontinued opioids at 12 months, measured by self-report.ResultsOf 608 participants randomized (mean age, 61 years; 362 female [60%]; median daily morphine equivalent dose, 46 mg [IQR, 25 to 79]), 440 (72%) completed 12-month follow-up. There was no statistically significant difference in PROMIS-PI-SF-8a scores between the 2 groups at 12-month follow-up (−4.1 in the intervention and −3.17 in the usual care groups; between-group difference: mean difference, −0.52 [95% CI, −1.94 to 0.89]; P = .15). At 12 months, opioid discontinuation occurred in 65 of 225 participants (29%) in the intervention group and 15 of 208 participants (7%) in the usual care group (odds ratio, 5.55 [95% CI, 2.80 to 10.99]; absolute difference, 21.7% [95% CI, 14.8% to 28.6%]; P < .001). Serious adverse events occurred in 8% (25/305) of the participants in the intervention group and 5% (16/303) of the participants in the usual care group. The most common serious adverse events were gastrointestinal (2% in the intervention group and 0% in the usual care group) and locomotor/musculoskeletal (2% in the intervention group and 1% in the usual care group). Four people (1%) in the intervention group received additional medical care for possible or probable symptoms of opioid withdrawal (shortness of breath, hot flushes, fever and pain, small intestinal bleed, and an overdose suicide attempt).Conclusions and RelevanceIn people with chronic pain due to nonmalignant causes, compared with usual care, a group-based educational intervention that included group and individual support and skill-based learning significantly reduced patient-reported use of opioids, but had no effect on perceived pain interference with daily life activities.Trial Registrationisrctn.org Identifier: ISRCTN49470934

A Group-Based Intervention to Reduce Opioid Use for Chronic Pain

“…At 4-month follow-up, soon after the end of tapering, participants randomized to the study intervention had significant improvements in the Short Form 12 mental component score and the Hospital Anxiety and Depression Scale. 1 We agree that one size will not fit all when seeking help with opioid tapering. Although Quinlan and Wiech believe that a specialist clinic approach to opioid tapering is superior to the I-WOTCH approach for people with more complex problems seen in a pain clinic, we are not aware of any objective evidence to support this view.…”

“…4 The opioid tapering guidance referenced by Quinlan and Wiech was published in 2020, long after we had designed our study. 1 More importantly, this guidance did not state that a 10% taper is no longer recommended; it stated that a 10% taper may be inappropriate for people taking high-dose opioids with multiple comorbidities. 5 These patients were not included in our study.…”

“…Furthermore, we did not use a fixed 10% taper plan. 1 Nurses worked with participants to agree on a tapering plan suitable for them, and slowing or pausing of the taper was allowed.…”

“…To the Editor The I-WOTCH (Improving the Wellbeing of People With Opioid Treated Chronic Pain) study compared a nurse-led intervention vs a self-management strategy for opioid tapering. After the intervention, 29% of patients discontinued opioids compared with 7% of controls.…”

A Group-Based Intervention to Reduce Opioid Use for Chronic Pain—Reply

“…In Reply The I-WOTCH study results are most relevant to our population of interest: people treated in primary care using strong opioids, as defined by the British National Formulary at the time we developed the study. We do not know how successful our approach might be in a pain clinic population.…”