Opioid Withdrawal, Pain Management Go Hand-in-Hand

                                             

Opioid reduction paired with alternative treatments such as cognitive behavioral therapy can reduce pain and improve function and quality of life for injured workers with chronic pain. Those of us who work in this field have known this for years; now, finally, we have the first bit of evidence to back it up.

But a new report also points to a tremendous knowledge gap among providers as to how to wean chronic pain patients off long term opioid use. The findings of this study should be used to spur the conversation about opioid withdrawal in the workers’ compensation system.

• Is your company using alternatives to opioids for injured workers with chronic pain?
• Do you have many claims involving long term opioid therapy?
• Have you seen injured workers get off long term opioid treatment and have good outcomes?

Findings

The Veterans Health Administration funded research that retrospectively reviewed 67 clinical studies addressing dose reduction or discontinuation of long term opioid therapy for chronic pain. The more than 12,000 patients included in the studies had volunteered to be weaned off the drugs. Even though guidelines recommend reducing or eliminating these drugs for chronic pain, there has been very little research about the actual effects on patient outcomes.

The authors admitted that the studies they found had poor methodologies or low sample sizes and were not top quality. Nevertheless, their findings are among the first to give credence to alternatives to treat chronic pain.  

The researchers categorized the studies into 8 intervention types, including behavioral interventions, such as CBT. In one of the “good quality” trials, an 8-week group intervention based on CBT and mindfulness meditation was compared with “usual care” among patients receiving long term opioid therapy. Even though the intervention did not explicitly encourage dose reduction, “the mean change in the daily opioid dose from baseline to 26 weeks was -10.1mg morphine equivalent dose in the intervention group compared with -0.2mg MED in the control group.” We can only imagine how much better the results might have been if dose reduction had been encouraged.

The researchers also looked at patient outcomes when the opioids were reduced or eliminated. They said “findings from this systematic review suggest that pain, function, and quality of life may improve during and after opioid dose reduction.”

Knowledge Gap

Some of the findings shed light on why injured workers with chronic pain continue to be prescribed long term opioid therapy.

“In routine practice, discontinuation of long term opioid therapy is uncommon, ranging from 8 percent to 35 percent in prior cohort studies,” the authors wrote. Also, “in a survey of patients receiving high-dose opioid medications for chronic pain, nearly half reported wanting to cut down or stop, yet 80 percent were receiving high-dose opioids 1 year later.” And, “among patients who had a nonfatal overdose while being prescribed long term opioid therapy, 91 percent continued use of opioid medications after the overdose.”

These discouraging numbers point to the need to help clinicians understand the need for, and resources available to help injured workers get off the drugs. But simply taking them off opioids without appropriate interventions can cause withdrawal symptoms and increased pain, among other problems.

Tapering Off Opioids

Injured workers in chronic pain on extended opioid therapy need help from experts trained in assessment and treatment. Our Supervised Withdrawal of Opioid Program (SWOP), for example, is delivered by an Addiction Medicine Specialist and a Health Psychologist. Their first step is to evaluate and treat injured workers who are on an opioid regimen that does not meet practice guidelines or other triggers.   

This 12-week program begins with an assessment followed by a recommended treatment plan based on the specific needs of the injured worker. Since many of these patients have specific psychosocial factors, the care must be tailored to address them. That means opioid withdrawal is just one aspect of the overall treatment plan.

One of the most important pieces of the plan is to help the injured worker understand what chronic pain really is so he doesn’t have unrealistic expectations. And while the patient wants anything that will make the pain vanish, he needs to understand that, like other chronic conditions, there is no cure.

That doesn’t mean that injured workers have to be in debilitating pain forever. Once they understand and accept the facts about their pain, they can learn how to manage it instead of being controlled by it. Taking control of their pain and their lives can significantly improve an injured worker’s function and quality of life and, yes, reduce his subjective experience of pain.

Learning to cope with the pain is done simultaneously with opioid withdrawal. The injured worker learns techniques to manage his pain without the use of opioids, which are typically ineffective in relieving the pain.

Through programs such as SWOP, the injured worker changes the negative thoughts and emotions help drive his chronic pain. He learns to take responsibility for his pain and his life.

The final segment of SWOP is the maintenance stage, involving addiction counseling and behavioral pain management. Crucial to this phase is relapse planning and prevention, where the injured worker learns how to avoid backsliding into opioid use.

Conclusion

The workers’ compensation system is making great headway in stemming the opioid epidemic. Recent reports indicate fewer patients are being prescribed the drugs, and less of the industry’s money is being spent on them.

But to truly eradicate the problem, providers, payers and other stakeholders need to embrace alternatives to treating chronic pain, such as CBT. Those injured workers who are already on long term opioid therapy with no functional improvement need to be exposed to programs to help them wean off the drugs and learn to cope with their pain.

We’d like to hear about your experiences with injured workers who have chronic pain.

• Is your company using alternatives to opioids for injured workers with chronic pain?
• Do you have many claims involving long term opioid therapy?
• Have you seen injured workers get off long term opioid treatment and have good outcomes?

Please share your thoughts with us.

Integrated Medical Case Solutions (Ascellus) is a national network of Health Providers in Psychology that delivers cognitive behavioral therapy (CBT) for chronic pain, trauma and insomnia across the country for the workers’ compensation industry.

For additional information, contact us at The Ascellus Group, or visit our website http://www.cope-with-pain.com.  Please join our LinkedIn group, at COPE with Pain.