Connect
MJA
MJA

Opioid cessation is associated with reduced pain and improved function in people attending specialist chronic pain services

Hilarie Tardif, Christopher Hayes and Samuel F Allingham
Med J Aust 2021; 214 (9): 430-432. || doi: 10.5694/mja2.51031
Published online: 3 May 2021

Practitioners who prescribe opioid medications for people with chronic non‐cancer pain must navigate increasingly stringent policy requirements,1 research findings questioning the benefit of opioids for such patients,2 and patients who fear uncontrolled pain if opioids are withdrawn.3

In Australia and New Zealand, people with chronic non‐cancer pain may be referred to specialist pain management services, most of which participate in the electronic Persistent Pain Outcomes Collaboration (ePPOC; https://www.uow.edu.au/ahsri/eppoc), an initiative for collecting standardised information about their patients, the services they provide, and the outcomes of treatment. This information is used at point of care, and for reporting, benchmarking, and research.

To explore the impact of changes in opioid use on outcomes for patients, we analysed ePPOC data collected at 67 pain services (online Supporting Information) during January 2015 – June 2020. We extracted data for all patients with completed episodes of care and who had answered questions about opioid use at referral and episode end. We summarised their characteristics and outcomes as means with standard deviations (SDs). All analyses were conducted in SAS 9.4. Our study was approved by the University of Wollongong and Illawarra and Shoalhaven Local Health District health and medical human research ethics committee; reference, 2019/ETH03804).

The mean age of the 10 302 patients who provided information at both referral and at the end of their treatment episodes was 49.5 years (SD, 14.4 years); 5807 were women (56.4%), and 3490 had experienced their pain for more than five years (33.9%). The most frequent site of their main pain was the back (3936 patients; 38.2%).

A total of 6340 patients (61.5%) were using opioid medications at referral (Box 1); their mean oral morphine equivalent daily dose4 was 56.3 mg (SD, 75.3 mg), the median daily dose was 31.0 mg (interquartile range [IQR], 15–75 mg). They reported higher mean pain scores than patients not using opioids at referral (6.2 [SD, 1.6] v 5.8 [SD, 1.7]) and greater interference in daily activities (7.2 [SD, 1.8] v 6.5 [SD, 2.0]; each measured with the Brief Pain Inventory5). Mean values for depression, anxiety, stress, pain catastrophising, and pain self‐efficacy were also worse for people using opioid medications (data not shown).

The most frequent service events were individual appointments with medical and allied health staff (35 678 of 55 012 events, 65%) and group pain programs (18 841 events, 34%); there were 493 procedural interventions (1%). The median episode length was 175 days (IQR, 99–322 days).

Opioid prescribing varies between pain services, including direct prescribing by the pain specialist and recommendations to patients’ general practitioners. However, a major focus of multidisciplinary care is supporting patients to reduce their opioid use, which typically involves collaboration between the patient, their GP, and the pain service.

By the end of their treatment episodes, 1724 patients who reported using opioids at referral (27.2%) had stopped doing so, 1234 patients (19.5%) had reduced their dose by at least 50% and 3382 patients (53.3%) had either not changed, increased, or reduced opioid use by less than 50%. For each group, scores had improved in each clinical domain, and the changes were greatest for patients who had ceased opioid use, as were the proportions experiencing clinically significant improvement. Scores for measures specifically related to pain experience (pain severity, interference, catastrophising and self‐efficacy) at the end of treatment were similar to or better than those of patients who had not been using opioids at referral, despite greater initial pain severity. Conversely, the smallest mean improvements were for the patients who had not reduced opioid use by at least 50% (Box 2).

Although our study was limited by its retrospective nature, the lack of follow‐up of patients who did not complete treatment, and its restriction to specialist pain practices, our findings are encouraging. We found that significant clinical improvements are possible for people with chronic non‐cancer pain attending multidisciplinary pain management services in Australia and New Zealand, even as they discontinue opioid medications. The challenge is to extend these services and supported self‐management skills to primary and community care.

 

Box 1 – Opioid use by patients at referral and at the end of treatment in specialist pain clinics


* Opioid therapy was initiated for 536 of patients who had not being using opioid medications at referral (13.5%).  Opioid use had been reduced by less than 50% for 1025 patients (30.3%), not changed for 878 patients (26.0%), and increased for 1479 patients (43.7%).

 

Box 2 – Mean pain and psychometric scores, and changes in scores between referral and end of treatment (with standard deviations), by opioid use at the two time points

Clinical domain

Patients not using opioids at referral

Patients who were using opioids at referral


Ceased taking opioids

Reduced opioid use by at least 50%

Other*


Total number of patients

3962

1724

1234

3382

Pain severity (BPI5)

3787

1646

1174

3215

 Referral

5.8 (1.7)

6.1 (1.7)

6.3 (1.6)

6.3 (1.6)

 Episode end

4.9 (2.0)

4.9 (2.0)

5.5 (1.8)

5.8 (1.7)

 Change in score

–0.9 (1.7)

–1.2 (1.8)

–0.8 (1.6)

–0.5 (1.5)

 Clinically significant improvement

817/2997 (27%)

459/1410 (33%)

231/1035 (22%)

436/2827 (15%)

Pain interference (BPI5)

3905

1702

1219

3316

 Referral

6.5 (2.0)

7.1 (1.8)

7.3 (1.7)

7.2 (1.9)

 Episode end

4.9 (2.4)

5.0 (2.4)

5.7 (2.3)

6.2 (2.2)

 Change in score

–1.6 (2.2)

–2.1 (2.3)

–1.6 (2.1)

–1.0 (2.0)

 Clinically significant improvement

2050/3279 (63%)

1062/1546 (69%)

679/1133 (60%)

1481/3003 (49%)

Depression (DASS‐216)

3827

1673

1201

3240

 Referral

17.8 (12.1)

20.2 (12.4)

20.9 (12.6)

20.7 (12.4)

 Episode end

12.8 (11.1)

13.8 (11.6)

15.6 (12.0)

16.6 (11.9)

 Change in score

–5.0 (10.1)

–6.4 (11.0)

–5.3 (10.7)

–4.0 (10.2)

 Clinically significant improvement

1308/2231 (59%)

662/1100 (60%)

434/810 (54%)

1042/2190 (48%)

Anxiety (DASS‐216)

3821

1676

1191

3233

 Referral

12.1 (10.2)

13.3 (10.4)

14.1 (10.4)

13.7 (10.3)

 Episode end

10.1 (9.5)

10.9 (9.7)

11.9 (9.7)

12.5 (10.1)

 Change in score

–2.0 (8.2)

–2.4 (8.7)

–2.2 (8.4)

–1.2 (8.0)

 Clinically significant improvement

858/1972 (44%)

438/962 (46%)

288/716 (40%)

662/1904 (35%)

Stress (DASS‐216)

3818

1660

1191

3226

 Referral

19.8 (11.0)

21.1 (10.8)

21.9 (10.9)

21.2 (11.1)

 Episode end

15.6 (10.6)

16.6 (10.7)

17.9 (10.5)

18.6 (10.8)

 Change in score

–4.1 (9.6)

–4.5 (10.2)

–4.0 (9.3)

–2.6 (9.2)

 Clinically significant improvement

1154/1936 (60%)

553/905 (61%)

387/710 (55%)

898/1828 (49%)

Pain catastrophising (PCS7)

3796

1649

1174

3204

 Referral

26.3 (13.3)

28.1 (13.4)

28.5 (13.4)

28.3 (13.3)

 Episode end

18.3 (13.3)

17.9 (13.5)

20.9 (13.6)

22.1 (13.6)

 Change in score

–8.0 (11.6)

–10.2 (12.2)

–7.6 (11.1)

–6.2 (11.2)

 Clinically significant improvement

1425/2513 (57%)

714/1164 (61%)

435/841 (52%)

1056/2308 (46%)

Pain self‐efficacy (PSEQ8)

3860

1685

1210

3262

 Referral

24.0 (12.6)

20.6 (12.0)

18.6 (11.0)

18.9 (11.9)

 Episode end

32.1 (14.4)

32.0 (14.4)

26.9 (13.1)

24.0 (13.1)

 Change in score

+8.1 (12.7)

+11.5 (14.0)

+8.3 (12.7)

+5.1 (12.1)

 Clinically significant improvement

1433/2796 (51%)

827/1382 (60%)

504/1058 (48%)

1015/2773 (37%)


BPI = Brief Pain Inventory (range, 0–10); DASS‐21 = Depression Anxiety and Stress Scale (range, 0–42); PCS = Pain Catastrophising Scale (range, 0–52); PSEQ = Pain Self‐Efficacy Questionnaire (range, 0–60; higher scores indicate greater self‐efficacy).  * Opioid use by patients had been reduced by less than 50%, not changed, or increased.  †  For patients who reported at least moderate symptom severity at referral (see Supporting Information for definitions of clinically significant improvement).

Received 14 September 2020, accepted 5 February 2021

  • Hilarie Tardif1
  • Christopher Hayes2
  • Samuel F Allingham1

  • 1 Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW
  • 2 Hunter New England Health, Newcastle, NSW

Correspondence: hilarie@uow.edu.au

Acknowledgements: 

We thank the staff at the participating pain management services for collecting and collating the data we analysed.

Competing interests:

The electronic Persistent Pain Outcomes Collaboration (ePPOC) is funded by the participating services, NSW Health, the Victorian Department of Health and Human Services, the Victorian Transport Accident Commission, Worksafe Victoria, the Australian Department of Veterans’ Affairs, and the Accident Compensation Corporation (New Zealand). Hilarie Tardif and Samuel Allingham are employed by ePPOC.

  • 1. Therapeutic Goods Administration. Prescription opioids. May 2020. https://www.tga.gov.au/hubs/prescription-opioids (viewed Nov 2020).
  • 2. National Institute for Health and Care Excellence. Chronic pain: assessment and management. Evidence review for pharmacological management [draft]. Aug 2020. https://www.nice.org.uk/guidance/GID-NG10069/documents/evidence-review-10 (viewed Sept 2020).
  • 3. Stumbo SP, Yarborough BJ, McCarty D, et al. Patient‐reported pathways to opioid use disorders and pain‐related barriers to treatment engagement. J Subst Abuse Treat 2017; 73: 47–54.
  • 4. Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. Opioid calculator. 2019. http://www.opioidcalculator.com.au (viewed Sept 2020).
  • 5. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap 1994; 23: 129–138.
  • 6. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foundation of Australia, 1995.
  • 7. Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophizing Scale: development and validation. Psychol Assess 1995; 7: 524–532.
  • 8. Nicholas MK. The pain self‐efficacy questionnaire: taking pain into account. Eur J Pain 2007; 11: 153–163.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.