Group Support and Tapering Reduce Opioid Dependence in Chronic Pain Patients

Summary: A new treatment shows promising results in helping people stop long-term opioid use for managing chronic pain. The study revealed that an intervention program combining group support and individual guidance allowed one in five people to quit opioids within a year, without increasing their pain or requiring substitute medication.

The initiative, designed to teach alternative pain management techniques and assist gradual withdrawal, could potentially enhance patients’ quality of life and save NHS resources.

Key Facts:

1. The innovative intervention program helped one in five people cease their opioid use within one year without worsening their pain or resorting to substitute medication.
2. The program combines one-to-one and group support, providing alternative techniques for pain management and assistance with withdrawal symptoms.
3. Over 600 people participated in the study from 2017 to 2020, revealing a significant difference in opioid cessation rates between those who received the intervention and those under regular GP care.

Source: University of Warwick

Researchers at the University of Warwick and The James Cook University Hospital, Middlesbrough have led a clinical trial, funded by the National Institute for Health and Care Research (NIHR), on a new treatment that can help people stop needing to use opioid painkillers to manage chronic pain.

There are over 1 million people in the UK on prescription opioids*, over 50,000 of whom have been taking these for 6 months or more*, at an estimated cost of £500 million to the NHS annually.

Recent NHS initiatives have managed to reduce opioid prescribing by eight percent, saving an estimated 350 lives.

New research has found evidence that could help many more people stop their opioid painkiller use.

Despite the evidence that taking opioids long term is harmful there are currently no alternative treatments available to safely help people who are coming off opioids and still dealing with chronic, non-cancer pain.

A team of researchers and clinicians have developed and successfully trialed an intervention program designed to guide people in coming off prescription painkillers, taper their opioid intake and learn how to manage their pain using alternative techniques with a course which combines one-to-one and group support.

1 in 5 people came off opioids within one year

The study, titled I-WOTCH (Improving the Wellbeing of people with Opioid Treated Chronic Pain), found that the intervention program helped 1 in 5 people come off their opioids within one year, without substituting medication and without making their pain worse.

Over 600 people took part in the randomized controlled study between 2017 and 2020 who at the beginning of the trial had been regularly taking strong opioids for at least three months. The participants were recruited from GP practices from the North East of England and the Midlands.

The study compared two treatments, dividing participants randomly into two groups.  One group had access to their existing GP care, plus a self-help booklet and relaxation CD; the second group had the same and also took part in an intervention program specially developed by the study team.

The intervention program included sessions on coping techniques, stress management, goal setting, mindfulness, posture and movement advice, how to manage any withdrawal symptoms and pain control after opioids.

Participants completed questionnaires about their everyday functioning and painkiller intake at intervals throughout the trial.

After one year, 29 percent of people who took part in the intervention program, were able to fully come off their opioids completely, compared to just 7 percent who were treated with existing GP care, the self-help booklet and CD.

There was no difference between the two groups in terms of their pain, or how pain interfered with their lives.

Combined group and one-to-one support key to reduce opioid need

Harbinder Kaur Sandhu, Professor of Health Psychology at the University of Warwick, who led the clinical trial said: “Structured, group-based, psycho-educational self-management interventions help people to better manage their daily lives with a long-term condition, including persistent pain, but few of these have specifically targeted patients considering opioid withdrawal.

“The findings from the trial are extremely promising. Many people who have been taking prescription painkillers over a long period time suffer with harmful side effects but can feel reluctant to come off them because they think it could make their pain worse, or they do not know how to approach this with their clinician.

“Our trial has found a treatment that could help people to come off opioids, in a way that is safe, supportive and gradual. It’s a supported decision between the patient and the clinician, and not forced tapering.

“The program helps people to learn alternative ways to manage their pain and help overcome challenges of withdrawal and has the potential to give people an overall better quality of life.”

Opioids have little long-term impact on chronic pain

Professor Sam Eldabe, clinical trial co-lead and consultant in pain medicine at The James Cook University Hospital, said: “Our trial is the culmination of six years of work during which we learned that the harms from long term opioids extend beyond the individual into their social circle.

“Patients taking opioids lose interest in social interaction with family and friends and gradually withdraw from society into an opioid-induced mental fog.

“Despite appreciating the social impact of the drugs, most patients utterly dread a worsening of their pain should they attempt to reduce their opioids.

“Our study shows clearly that opioids can be gradually reduced and stopped within no actual worsening of the pain. This confirms our suspicions that opioids have very little long-term impact on persistent pain.”

Colin’s story

Colin Tysall, 81 from Coventry, was prescribed painkillers, including opioids to treat chronic back pain, as a result of working as an aircraft radiologist for 30 years.

“I was an industrial radiologist and wore my back out x-raying aircraft parts and handling heavy castings for jet engines. The castings could weigh up to 200lbs and even though we would move some of the castings around in stillages, it was still a strain. We were having to move these castings around very carefully, with no lifting equipment.”

Colin started experiencing sciatic pain down both of his legs and found that he had three slipped discs in his back. He describes the devastating impact of painkiller dependency:

“The treatment at the time was bedrest and painkillers. The tablets got stronger and stronger until eventually I was prescribed opioids,” said Colin.

“I spent so much time in bed that I lost the use of my legs and fell into a deep depression, so I was prescribed antidepressants too. I couldn’t look after my family, and at one point I tried to take my own life.

“I didn’t like being on tablets. They addled my brain, they made it difficult to think straight, my brain wasn’t functioning as it should. I would have nightmares a lot. As soon as I could come off them, I did.”

After spending 10 years visiting hospital to treat his back and mental health, Colin turned to alternative treatments to treat his pain.

“I found that the best treatment for me was exercise. I got involved with mental health self-health groups, and I became friends with people experiencing similar problems. We would walk and talk together, which was the opposite of the guidelines at the time, but I found it helped keep my mind off the pain, and it made it easier to cope.”

After spending a couple of years tapering his medication to a lower level, Colin was eventually able to come off the tablets altogether. Recently he has found that he is no longer suffering with the pain.

Colin retrained as an associate mental health manager, and he continues to work at Coventry and Warwick universities helping to train psychiatric and nursing students.

Most recently, Colin got involved with the University of Warwick’s Clinical Trials Unit and has been helping support patients in the I-WOTCH clinical trial group support sessions as a trained I-WOTCH lay person.

The full intervention programme consisted of an 8-to-10-week course and included:

The group sessions consisted of three full day sessions per week. The group sessions included education about opioids and pain, case studies of people who have successfully tapered, learning self-management skills for pain and challenging beliefs.

There was also the opportunity to practice techniques such as mindfulness and distraction. The group sessions were facilitated by a trained I-WOTCH nurse and a trained I-WOTCH lay person (someone who had personal experience of pain and opioid tapering).

• Tailored one-to-one support and opioid tapering

In addition to the group sessions, people in the study were also given one-to-one sessions with the nurse to offer support and most importantly tailored advice for the opioid tapering which was delivered face-to-face and through telephone calls.

A tapering app designed for the study was used to calculate a reduction on opioid intake based on current guidance at that time and actioned by the participants’ GPs.

About this addiction and pain research news

Author: Bron Mills
Source: University of Warwick
Contact: Bron Mills – University of Warwick
Image: The image is credited to Neuroscience News

Original Research: Closed access.
“Reducing Opioid Use for Chronic Pain With a Group-Based Intervention: A Randomized Clinical Trial” by Harbinder Kaur Sandhu et al. JAMA

Abstract

Reducing Opioid Use for Chronic Pain With a Group-Based Intervention: A Randomized Clinical Trial

Importance  

Opioid use for chronic nonmalignant pain can be harmful.

Objective  

To test whether a multicomponent, group-based, self-management intervention reduced opioid use and improved pain-related disability compared with usual care.

Design, Setting, and Participants  

Multicentered, 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.

Intervention  

Participants 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 Measures  

The 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.

Results  

Of 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 Relevance  

In 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 Registration  

isrctn.org Identifier: ISRCTN49470934