Effectiveness of non-opioid interventions to reduce opioid withdrawal symptoms in patients with chronic pain: a systematic review

Abstract

Background Dealing with the opioid crisis, medical doctors are keen to learn how to best treat opioid dependency in patients with chronic non-cancer pain. Opioid replacement therapy is commonly used, but success rates vary widely. Since many patients still experience severe withdrawal symptoms, additional interventions are necessary. Objective To review the effectiveness of interventions in the treatment of withdrawal symptoms during opioid tapering or acute withdrawal in patients with long-term non-cancer pain. Methods A systematic review was conducted in Embase.com, MEDLINE, Web of Science, PsycINFO, and Cochrane CENTRAL register of trials. Studies eligible for inclusion were (non-)randomized controlled trials in adults with long-term opioid prescriptions for non-cancer pain. Included trials had to compare a non-opioid intervention to placebo, usual care, no treatment, or non-opioid drug and had to report on withdrawal symptoms as an outcome. Study quality was assessed with the 2.0 Cochrane risk of bias (RoB) tool. Evidence quality was rated following the GRADE approach. Results One trial (n = 21, some concerns regarding RoB) compared Varenicline to placebo. There was no statistically significant between-group reduction of withdrawal symptoms (moderate-quality evidence). Conclusions Evidence from clinical trials on interventions reducing withdrawal symptoms is scarce. Based on one trial with a small sample size, no firm conclusion can be drawn. Meanwhile, doctors are in dire need for therapeutic options to tackle withdrawal symptoms while tapering patients with prescription opioid dependence. We hope this review draws attention to this unfortunate research gap so that future research can provide doctors with answers.

Family Practice substance use disorder theme issue: commentary

“… 10 Remarkably, the systematic review of controlled trials of interventions for opioid withdrawal during opioid tapering, found only 1 study meeting inclusion criteria. 11 This study found no between group differences in opioid withdrawal symptoms between varenicline vs placebo. There is a great need to develop improved strategies for treating withdrawal in opioid tapering.…”

“…Managing opioid withdrawal was investigated by Quattlebaum et al’s 10 case study and Langejan et al’s 11 systematic review. The case study reports the use of rapid administration of high-dose buprenorphine for buprenorphine precipitated withdrawal in a patient who did not respond to recommended dose escalation.…”

Opioid Kullanım Bozukluğu arındırma sürecinde ağrının yönetimi: Konfor Kuramı ve Nörobilim temelinde bir yaklaşım

“…Klinik deneyimler, BNK'nın azaltılmaya başlaması ile ortaya çıkabilen özellikle ağrı gibi belirtilerin iyi yönetilemediği durumlarda tedaviyi yarıda bırakma ve tekrar kullanmaya başlama durumlarının sık yaşandığını göstermektedir. Bununla birlikte literatürde özellikle bu süreçte ortaya çıkan belirtileri azaltan müdahalelere ilişkin klinik çalışmalardan elde edilen kanıtların yeterli olmadığı, terapötik seçeneklere yoğun bir ihtiyaç duyulduğu bildirilmektedir (32).…”

Feasibility study of a Behavioural Intervention for Opioid Reduction (BIOR) for patients with chronic non-cancer pain in primary care: a protocol

“…Lack of alternative treatment for CNCP and the perception of infrequent adverse events have contributed to the continuing opioid crisis 11 20. Moreover, prescribers may be reluctant to deprescribe, particularly if there is limited access to effective pain management treatments 21 22.…”

“…Patients who are taking high doses for long periods demonstrate high psychological distress and low self-efficacy,33 34 highlighting the importance of working with the patient for behaviour change and pain acceptance. Opioid tapering has found improvements in pain response and pain tolerance, without a decline in function or quality of life,20 while a recent systematic review showed high patient interest in support for tapering 32. GP supervised tapering and Multidisciplinary Team (MDT) group therapeutic sessions are advocated to reduce long-term opioid use 35–37…”