How to wean friends and influence health: Opioid weaning and discontinuation aided by a simple health and wellness coaching program

Heath B. McAnally, MD, MSPH; Stormie M. Thompson, DO; Paul Okediji, MBChB

doi:10.5055/jom.2023.0759

Authors

Heath B. McAnally, MD, MSPH https://orcid.org/0000-0003-3924-5948
Stormie M. Thompson, DO
Paul Okediji, MBChB

DOI:

https://doi.org/10.5055/jom.2023.0759

Keywords:

chronic opioid use, opioid weaning, opioid discontinuation, health and wellness coaching, pain neuroscience education, multidisciplinary, therapeutic alliance

Abstract

Objective: To evaluate whether a simple health and wellness coaching (HWC) program embedded within routine clinical practice resulted in improved opioid weaning and discontinuation.

Design: Retrospective double cohort study comparing longitudinal opioid use data and numeric pain scale ratings for patients in each group.

Setting: Single noninstitutional subspecialty pain management practice.

Participants: Twenty (daily opioid using) patients undergoing a multifocal HWC program with integrated pain neuroscience education (PNE) compared to 20 age- and gender-matched (daily opioid using) patients undergoing usual care.

Intervention: A systematized series of interactive self-management topics/lessons on basic health topics pertinent to chronic pain, eg, posture, mobility, nutrition, sleep, stress management, and PNE.

Main outcome measures: Daily morphine milligram equivalents (MMEs) trajectory and discontinuation success (hypothesis and outcome measure formulated before data collection); numeric pain scale rating trajectory (hypothesis and outcome measure formulated after data collection).

Results: MME decrease was significantly greater among cases (93.5 percent) than controls (50 percent; p = 0.004) as was discontinuation of opioids (30 percent vs 0). Cases reported decreased longitudinal 10-digit pain scale rating (–0.8) compared to controls (+0.1) without statistical significance.

Conclusions: Providing simple and salient HWC including PNE within pain management can significantly improve opioid weaning and discontinuation while mitigating pain.

Author Biographies

Heath B. McAnally, MD, MSPH

Northern Anesthesia and Pain Medicine, Eagle River, Alaska; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington

Stormie M. Thompson, DO

Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington

Paul Okediji, MBChB

MedInsight Research Institute, Rehovot, Israel

References

Centers for Disease Control and Prevention: CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR. 2016; 65(1): 1-49.

Veterans Administration/Department of Defense: VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Washington, DC: Veterans Administration, 2010. Available at http://www.va.gov/painmanagement/docs/cpg_opioidtherapy_fulltext.pdf. Accessed January 14, 2022.

Manchikanti L, Kaye AM, Knezevic NN, et al.: Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2017; 20(2S): S3-S92.

Goesling J, DeJonckheere M, Pierce J, et al.: Opioid cessation and chronic pain: Perspectives of former opioid users. Pain. 2019; 160(5): 1131-1145. DOI: 10.1097/j.pain.0000000000001493.PMID: 30889052.

Frank JW, Levy C, Matlock DD, et al.: Patients’ perspectives on tapering of chronic opioid therapy: A qualitative study. Pain Med. 2016; 17: 1838-1847.

Berna C, Kulich RJ, Rathmell JP: Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice. Mayo Clin Proc. 2015; 90(6): 828-842. DOI: 10.1016/j.mayocp.2015.04.003.

Robinson JP, Dansie EJ, Wilson HD, et al.: Attitudes and beliefs of working and work-disabled people with chronic pain prescribed long-term opioids. Pain Med. 2015; 16(7): 1311-1324. DOI: 10.1111/pme.12770.

Matthias MS, Johnson NL, Shields CG, et al.: “I'm not gonna pull the rug out from under you”: Patient-provider communication about opioid tapering. J Pain. 2017; 18(11): 1365-1373. DOI: 10.1016/j.jpain.2017.06.008.

Huffman KL, Sweis GW, Gase A, et al.: Opioid use 12 months following interdisciplinary pain rehabilitation with weaning. Pain Med. 2013; 14(12): 1908-1917. DOI: 10.1111/pme.12201.

Frank JW, Lovejoy TI, Becker WC, et al.: Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: A systematic review. Ann Intern Med. 2017; 167(3): 181-191. DOI: 10.7326/M17-0598.

US Department of Health and Human Services: HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. Available at https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf. Accessed November 29, 2020.

Darnall BD, Ziadni MS, Stieg RL, et al.: Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Intern Med. 2018; 178(5): 707-708.

Sud A, Armas A, Cunningham H, et al.: Multidisciplinary care for opioid dose reduction in patients with chronic noncancer pain: A systematic realist review. PLoS One. 2020; 15(7): e0236419. DOI: 10.1371/journal.pone.0236419.

Eccleston C, Fisher E, Thomas KH, et al.: Interventions for the reduction of prescribed opioid use in chronic noncancer pain. Database Syst Rev. 2017; 11(11): CD010323. DOI: 10.1002/14651858.CD010323.pub3.

Canlas BR, Dawson TC, Hollrah LN, et al.: Restoring function in veterans with complex chronic pain. Fed Pract. 2017; 34(10): 42-47.

Darnall BD, Mackey SC, Lorig K, et al.: Comparative effectiveness of cognitive behavioral therapy for chronic pain and chronic pain self-management within the context of voluntary patient-centered prescription opioid tapering: The EMPOWER study protocol. Pain Med. 2020; 21(8): 1523-1531. DOI: 10.1093/pm/pnz285.

Cummings SR, Ernster V, Hulley SB: Designing a new study: I. Cohort studies. In Hulley SB, Cummings SR (eds.): Designing Clinical Research. Baltimore: Wilkins & Wilkins, 1988: 63-74.

Available at https://www.cms.gov/Medicare/Prescription-Drug-coverage/PrescriptionDrugCovContra/Downloads/Opioid-Morphine-EQ-Conversion-Factors-Aug-2017.pdf. Accessed May 15, 2021.

Fudin J, Raouf M, Wegrzyn EL, et al.: Safety concerns with the centers for disease control opioid calculator. J Pain Res. 2017; 11: 1-4.

Available at https://pubchem.ncbi.nlm.nih.gov/compound/Tapentadol#section=Pharmacology-and-Biochemistry. Accessed May 15, 2021.

McNerney NA, Losensky MJ, Lash MM, et al.: Low theoretical fidelity hinders the research on health coaching for opioid reduction: A systematic review of randomized controlled trials. PLoS One. 2020; 15(10): e0241434. DOI: 10.1371/journal.pone.0241434.

Rethorn ZD, Pettitt RW, Dykstra E, et al.: Health and wellness coaching positively impacts individuals with chronic pain and pain-related interference. PLoS One. 2020; 15(7): e0236734. DOI: 10.1371/journal.pone.0236734.

Hackshaw KV, Plans-Pujolras M, Rodriguez-Saona LE, et al.: A pilot study of health and wellness coaching for fibromyalgia. BMC Musculoskelet Disord. 2016; 17(1): 457. DOI: 10.1186/s12891-016-1316-0.

Rogers AH, Garey L, Raines AM, et al.: Anxiety sensitivity and opioid use motives among adults with chronic low back pain. Exp Clin Psychopharmacol. 2020; DOI: 10.1037/pha0000381.

Martel MO, Finan PH, McHugh RK, et al.: Day-to-day pain symptoms are only weakly associated with opioid craving among patients with chronic pain prescribed opioid therapy. Drug Alcohol Depend. 2016; 162: 130-136. DOI: 10.1016/j.drugalcdep.2016.02.047.

Malinoff HL, Barkin RL, Wilson G: Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. Am J Ther. 2005; 12(5): 379-384.

Daitch J, Frey ME, Silver D, et al.: Conversion of chronic pain patients from full-opioid agonists to sublingual buprenorphine. Pain Physician. 2012; 15(3 Suppl.): ES59-ES66.

Zekry O, Gibson SB, Aggarwal A: Subanesthetic, subcutaneous ketamine infusion therapy in the treatment of chronic nonmalignant pain. J Pain Palliat Care Pharmacother. 2016; 30(2): 91-98.

Marchetti F, Coutaux A, Bellanger A, et al.: Efficacy and safety of oral ketamine for the relief of intractable chronic pain: A retrospective 5-year study of 51 patients. Eur J Pain. 2015; 19(7): 984-993.

Haroutounian S, Ratz Y, Ginosar Y, et al.: The effect of medicinal cannabis on pain and quality-of-life outcomes in chronic pain: A prospective open-label study. Clin J Pain. 2016; 32(12): 1036-1043.

Levine AB, Steven DA, Parrent AG, et al.: Successful long-term nerve root stimulation for chronic neuropathic pain: A real world. Pain Physician. 2017; 20(2): 95-106.

Caraway D, Walker V, Becker L, et al.: Successful discontinuation of systemic opioids after implantation of an intrathecal drug delivery system. Neuromodulation. 2015; 18(6): 508-515, discussion 515-516. DOI: 10.1111/ner.12318.

Hooten WM, Townsend CO, Bruce BK, et al.: The effects of smoking status on opioid tapering among patients with chronic pain. Anesth Analg. 2009; 108(1): 308-315. DOI: 10.1213/ane.0b013e31818c7b99.

Huffman KL, Rush TE, Fan Y, et al.: Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy. Pain. 2017; 158(7): 1380-1394. DOI: 10.1097/j.pain.0000000000000907.

Goesling J, Moser SE, Lin LA, et al.: Discrepancies between perceived benefit of opioids and self-reported patient outcomes. Pain Med. 2018; 19(2): 297-306.

Smit T, Rogers AH, Garey L, et al.: Anxiety sensitivity and pain intensity independently predict opioid misuse and dependence in chronic pain patients. Psychiatry Res. 2020; 294: 113523. DOI: 10.1016/j.psychres.2020.113523.

Helmerhorst GT, Vranceanu AM, Vrahas M, et al.: Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014; 96(6): 495-499.

Okifuji A, Hare BD: The association between chronic pain and obesity. J Pain Res. 2015; 8: 399-408.

Hays RD, Spritzer KL, Schalet BD, et al.: PROMIS®-29 v2.0 profile physical and mental health summary scores. Qual Life Res. 2018; 27(7): 1885-1891.