Opioid-Sparing Interventions in Acute and Chronic Pain: New Insights from Multicenter Trials

Prescription opioid use and opioid tapering are associated with significant health risks. Up to 8% of surgical patients are at risk for developing problematic opioid use after minor and major surgery and thus effective opioid sparing strategies are needed. To minimize tapering risks in patients taking opioids long term, the US, Australia, Canada, and the United Kingdom national guidances recommend tapering methods that are flexible, patient-centered, and with psychological supports. Each country cited limited evidence from few single-site studies and called for stronger evidence on tapering. This multidisciplinary workshop presents results from recent multicenter opioid sparing randomized controlled trials (RCTs) in acute and chronic pain in the USA and Europe.

Professor Darnall will present results from the national EMPOWER multisite RCT which compared the effectiveness of patient-centered tapering methods for 562 adults with chronic pain taking prescription opioids long term (pain intensity, 6.2±1.9; and total MEDD, 125.1±242). Participants engaged in a patient-centered opioid taper with close monitoring and e-supports, and were randomized to either: (1) Taper Only, (2) Taper + cognitive behavioral therapy (pain-CBT), or (3) Taper + chronic pain self-management program (CPSMP). No serious study related adverse events were recorded. Taper Only met trial success thresholds and CBT and CPSMP did not significantly improve taper outcomes at 12 months. Veteran site and higher baseline taper readiness predicted taper success. Dr. Darnall will also present published results for an RCT showing that a digital pain relief skills intervention resulted in quicker opioid cessation after breast cancer surgery compared to controls.

Dr Grelz will discuss key findings from the "Tapering from prescribed opioids in patients with chronic non-cancer pain (TOPIO) trial". In this multicenter RCT, encompassing 140 patients, (pain intensity 7,2±1.7 and MEDD 90±124) participants were randomized to 1) four-month tapering intervention supported by a physician and nurse, or 2) waiting-list to intervention. Intention to treat revealed 66% of participants in the tapering group successfully halved their opioid dose, and 41% discontinued opioids completely (number needed to treat = 2). Treatment adherence with 86% completing the intervention. Adverse events led to discontinued tapering for 3 participants. Secondary outcomes—including pain intensity, pain-related cognitions, mental health, and quality of life—did not differ significantly between groups at the four-month follow-up.

Dr Andréll will present results from two multicenter RCTs: one evaluating an opioid-free perioperative care pathway for patients undergoing laparoscopic bariatric surgery, and another assessing transcutaneous electrical nerve stimulation (TENS) for postoperative pain following laparoscopic cholecystectomy. Findings are complemented by qualitative interview studies from participants in both trials as well as health care professionals’ experience of TENS for treatment of postoperative pain. Both the opioid-free perioperative care pathway and TENS are effective interventions for treatment of postoperative pain, reducing need of opioids in the post-anesthesia care unit, with no difference in pain relief compared to conventional opioid treatment. The patients desire alternatives to pharmacological treatment in postoperative care. TENS offers the patient the possibility to actively participate in their pain management, enhancing autonomy.

Interactive discussion will highlight challenges and opportunities for clinical implementation.