Pain services effective, but high drop-out rate concerns

A LARGE study of patients with chronic non-cancer pain treated at multidisciplinary pain services has provided encouraging findings, with many able to cease or reduce their opioid medications.

However, experts say the high drop-out rate at such centres cannot be ignored amid increasing pressure to deprescribe opioids.

The retrospective study, published as a research letter in the MJA, was based on surveys of 10 302 patients who completed an episode of care at one of 67 pain services across Australia and New Zealand in 2015–2020. A third of the patients had experienced pain for more than 5 years – most commonly back pain.

Of the 6340 patients who were using opioids at referral, 27.2% had stopped using them by the time of their last appointment – an average of 6 months later. A further 19.5% had their dose reduced by at least 50%.

Although patients continued to experience pain at the time of their last visit, on average it interfered less with their daily activities compared with before treatment. Patients also scored better on measures of pain catastrophising, pain self-efficacy, depression, anxiety and stress after completing their episode of care.

The greatest improvements were seen among patients who ceased taking opioids, followed by those who substantially reduced their opioid use.

The findings come from the ongoing electronic Persistent Pain Outcomes Collaboration (ePPOC), established by the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists together with the University of Wollongong’s Australian Health Services Research Institute.

“These are encouraging results,” lead author and ePPOC founding member, Dr Chris Hayes, told InSight+. “They show that those who stick with the program are likely to do reasonably well.”

Although the study lacked a control group, Dr Hayes said it was unlikely the patients who experienced improvement would have done so without the intervention.

“People with chronic back pain tend to get worse if they are not doing anything,” he said.

“The evidence shows they need to move better, eat better and think differently if they are to improve, and that is the focus of most multidisciplinary care.”

Drop-out rate

However, a major limitation with the latest study, Dr Hayes acknowledged, was that it did not reflect the extremely high drop-out rates at many centres – “often 80–90%”.

Dr Hayes said he believed the problem had worsened since the Therapeutic Goods Administration issued advice in May 2020 that opioids are not indicated to treat chronic non-cancer pain.

“It seems many GPs, feeling hassled by the regulators, have referred patients on to us, but many of those patients don’t want to participate,” he said.

“It is an uphill battle getting patients to stick with it, especially when so many people have been conditioned by the health care system to focus on passive receipt of a drug rather than active treatment.”

Dr Hayes said a typical multidisciplinary pain management service would offer a long initial appointment to delve into a patient’s pain history to identify triggering experiences.

“Then in the treatment phase, the pain specialist works together with clinicians such as a physiotherapist and a clinical psychologist to package together a self-help plan involving things such as strength training, anti-inflammatory eating and slowly coming down off opioid medications,” he said.

Reducing opioid dependency is a major goal for chronic pain services, Dr Hayes said, adding:

“There is no reasonable evidence for opioids’ efficacy in this setting but there are substantial harms.”

There are around 1000 opioid-related deaths in Australia each year – most often accidental overdoses, he noted.

Deprescribing controversial

Professor Nick Lintzeris, Conjoint Professor in the Department of Addiction Medicine at the University of Sydney’s Central Clinical School, who was not involved in the MJA study, said reducing the number of opioid-related deaths in Australia was not a simple matter of deprescribing, which despite good intentions, could make the situation worse.

Professor Lintzeris argued that addiction to opioids was an historical “blind spot of pain medicine”.

“Many patients who take long term opioids aren’t doing it only for management of a particular pain condition. Many don’t differentiate their comorbidities the way doctors do. They’re just feeling really bad, sore, in a bad mood and they can’t sleep. Many feel that their opioid medication provides general relief,” he said.

“If you ask them, they will say they are using the medication ‘to cope’. Many are addicted, meaning they have a diminished ability to control their use of the drug.”

Professor Lintzeris said a major question unanswered by the latest study was whether those who stopped taking opioids had switched to something else.

“Are they drinking more? What about their benzodiazepine use?” he asked.

“Around 10–20% of patients prescribed opioids for chronic pain are dependent on opioids, and if their doctors stop prescribing it, experience suggests many will turn to other drugs, often illicit medications, which are far less safe,” he said.

Professor Lintzeris said the latest study showed that pain management services were “at least worth a try for non-cancer patients prescribed long term opioids”.

However, he cautioned against drawing any strong conclusions, given the study only included patients who continued with the service.

“These are ‘the survivors’,” he said. “What’s more, it’s possible that the ones who got better were less unwell to begin with. Most patients (53%) still had no significant decrease in their opioid medications.

“We need a rational approach to opioid prescribing, not a simplistic one. Some patients will need their GP to keep prescribing their opioid medication while they are on the wait list to see a pain or addiction medicine specialist.

“We need to ensure that we do not stigmatise those patients who are unable to stop opioid medications,” he added.

Drilling down on the data

Dr Paresh Dawda, a member of the Royal Australian College of General Practitioners Expert Committee – Quality Care, who was not involved in the MJA study, said it was encouraging to see that just under half of patients from ePPOC were able to stop or reduce opioids.

Nevertheless, he too questioned the sustainability of the benefits: “How many may return to opioid use or increase opioids in the future?”

Dr Dawda said it would be useful to see more data on which subcohorts were most likely to benefit from the intervention, and which components of the multidisciplinary service helped achieve the benefit.

Noting the median age in the study was just 49.5 years, Dr Dawda said more evidence was needed to guide pain management and appropriate prescribing in older cohorts with multimorbidity.

“The authors articulate a challenge being extending services and supported self-management skills to primary and community care – this is ultimately where such care needs to occur,” he said.

Most pain management services captured in the ePPOC data are publicly funded multidisciplinary clinics, located at public hospitals or within primary health care networks.

Waiting times typically ranged from 2 to 6 months, Dr Hayes said.

Although many private clinics have opened in the past decade, Dr Hayes said a relatively small proportion of those participated in ePPOC.

“Many of the private clinics in Australia have a greater focus on medical interventions such as implanted spinal cord stimulators, which is very different to the ‘slow medicine’ focus of most public multidisciplinary pain services,” he said.