With Behavioral Support in Place, Opioid Dose Reduction Does Not Exacerbate Pain or Function

Reducing high-dose opioid therapy does not worsen pain severity, functional ability, or aberrant drug-related behaviors in chronic pain patients when concurrent biopsychosocial services are offered, suggests a scientific poster presented at the American Academy of Pain Medicine (AAPM) 2014 Annual Meeting, held March 6-9, 2014, in Phoenix, AZ.

For their retrospective, observational pilot study, David J. DiBenedetto, MD, a founding partner and current Medical Director of the interdisciplinary outpatient Boston PainCare Center (BPC) in Massachusetts, and his colleagues “examined the impact of high-dose opioid reduction on subjects’ behaviors and perceived functioning,” in light of the facts that “the efficacy of high-dose opioid treatment has been recently called into question,” and “high-dose opioid use has been associated with adverse effects such as hypersensitization, mood disorders, and endocrinological dysfunction.”

With that purpose in mind, the poster authors recruited chronic pain patients who enrolled in BPC’s Medication Management Program, which provides “multilevel care plans designed to offer the medical, rehabilitative, and behavioral serves needed to help patients adaptively manage their pain to improve function and quality of life.”

After reviewing the patients’ medical charts, the researchers sorted the subjects into 2 study populations: a high-dose reduction group, which had a starting opioid dose ≥150 mg of morphine sulfate (MSO4) equivalent and underwent an opioid dose reduction, and a randomly selected control group, which had any range of starting opioid dose levels but did not undergo an opioid dose reduction. Ultimately, 60 subjects with an average age of 53 were included in the high-dose reduction group, while 49 subjects with a mean age of 51 participated in the control group.

The BPC investigators also identified 2 patient subgroups: those with starting Matheson Functional Pain Scale (MFPS) ratings ≥7, and those with the highest MSO4 dose at enrollment, who consisted of 10 subjects from the reduction group and another 10 control subjects.

In addition to MFPS ratings that convey the functional impact of pain symptoms, the study’s outcome variables included modified Roland Morris Disability Index (RMDI-M) scores that measure perceived disability due to pain, and inconsistent urine drug testing results that show “the presence of a non-prescribed substance or the absence of the prescribed opioid medication,” the authors wrote.

At the end of the study period, the researchers found the average opioid dose among the high-dose reduction group decreased by 40%, from 508 mg of MSO4 equivalent at the start of the study to 305 mg. In contrast, the average MSO4 dose increased by 93% in the control group over the study period.

Even though their opioid therapy decreased, patients in the reduction group reported “no clinically significant changes in either functional pain severity or perceived functional abilities” on average — a finding that held true in the subgroups and was comparable to the results seen in the control group, which increased opioid therapy. Furthermore, both the reduction and control groups “exhibited a similar number of subjects with aberrant drug-related behaviors,” the authors wrote.

Given the success of the Medication Management Program in this study, the investigators said it has implications in “shifting evaluation of effectiveness of opioid therapy to more functional and behavioral measures, and evaluating effectiveness with societal costs in mind, including financial, work-related, and aberrant behaviors.” However, they noted “a more robust study is needed to determine the impact of both opioid reduction and elimination on functional and behavioral outcomes measures in this patient population,” as their pilot study had several limitations, including “lack of control for confounding factors that might influence the outcome measures, small sample size, and potential for bias during data collection and analysis.”