Reducing prescribed opioid use in chronic non-cancer pain

About 1 in 5 adults suffer from moderate or severe chronic pain that is not caused by cancer. Some people with this type of pain are treated with opioids (typically with drugs like morphine, codeine, oxycodone, fentanyl, or buprenorphine, either as tablets or as patches placed on the skin). It is not unusual for this medication to be ineffective or to stop working over time, and, sometimes, effective pain relief is not achieved despite doses being increased. Stopping using opioid drugs is not easy, especially when they have been used for some time, because stopping abruptly can cause unpleasant side effects. This review looked for high quality studies (randomised controlled trials) of treatments to help people safely stop taking opioids prescribed for their pain. Only two studies were found, and they investigated only 86 people. No conclusions can be drawn from this small amount of information. Non-randomised studies, not included in this review, do indicate that in most people intensive rehabilitation packages can bring about major reduction in opioid use. Reducing prescribed opioid use in chronic non-cancer pain is an important topic in need of more research.

Authors' conclusions: 

Both included studies were at significant risk of bias because of their small size, together with other important issues, including blinding. Because of this risk and the paucity of relevant studies, no conclusions can be drawn regarding the effectiveness of interventions for opioid withdrawal in chronic non-cancer pain.

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Background: 

Patients with chronic non-cancer pain who are prescribed and are taking opioids can have a history of long term high dose opioid use without effective pain relief. In those without good pain relief, reduction of prescribed opioid dose may be the desired and shared goal of both patient and clinician. Simple unsupervised reduction of opioid use is clinically challenging, and very difficult to achieve and maintain.

Objectives: 

To investigate the effectiveness of different methods designed to achieve reduction or cessation of prescribed opioid use for the management of chronic non-cancer pain.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE from inception to 8th April 2013, as well as bibliographies.

Selection criteria: 

Included studies had to be randomised controlled trials comparing opioid users receiving an intervention with a control group receiving treatment as usual, active control, or placebo. The aim of the study had to include a treatment goal of dose reduction or cessation of opioid medication.

Data collection and analysis: 

We sought data relating to prescribed opioid use, adverse events of opioid reduction, pain, and psychological and physical function.

Main results: 

Two studies provided information on 86 participants. One compared electroacupuncture with sham acupuncture for 20 minutes twice a week for six weeks; there was no difference between treatments. The other followed 11 weeks of cognitive behavioural therapy with either therapeutic interactive voice response through a computer for four months or usual treatment; the active group had a significant reduction in opioid use, while the usual care group had a significant increase.

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