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.


Naloxone should be co-prescribed with opioids for long-term use
  • Strongly agree (49%, 46 Votes)
  • Agree (27%, 25 Votes)
  • Neutral (13%, 12 Votes)
  • Disagree (10%, 9 Votes)
  • Strongly disagree (1%, 1 Votes)

Total Voters: 93

Loading ... Loading ...

4 thoughts on “Pain services effective, but high drop-out rate concerns

  1. Janet Hedges says:

    Good grief lve never abused my medication or sold lt or been irresponsible with lt after ten years of use. Endometreosis destroyed my body and the deterioration over the years due to the deterioration in my body from head to foot as a result of over 40 operations for Endometreosis having a hysterectomy at age22 total colectomy at 29 and lts never stopped for me and now deterioration of all cartilage throughout my body. I’d love to not need opiods however without them l have zero quality of life and with them l continue to remain active and not bed bound. Doctors need to stop taring us all with the same brush. Thing is abusers will continue to get there fix no matter what you do but for folks like me end up attempting suicide without help and personally everything other avenue had been exhausted trying to manage pain and l would rather not need opiods either but sadly l have no quality of life without them. The suicide rate ls no longer just young folks. Older persons are giving up on life due to no help and or being punished for serious genuine medical conditions and after my research have discovered we now treat our animals and pets better than our fellow human. Across Australia every medical practise have folks either committing suicide or just giving up because they have no quality of life without help. Infact folks who require pain relief are now being treated as second class citizens and doctors are afraid to help. My doctor recently committed suicide because of government pressure. Fact also remains our government are aware that not everyone fits in the boxes and that many are dieing as a result.

  2. Lindsay Buttery says:

    I am very inclined to agree, re pain clinics and their relative uselessness at being flexible to suit individual needs. Having been a nurse, who’s career was destroyed following a very bad back injury in 1997, I have been reliant upon opiates since that time. Here’s the thing – I am very keen to get off these medications and, many times, have self titrated the dosage downward, to the point at which further titration is impossible due to the residual pain being far too severe to cope with even an unchallenging life structure. Over the now 24 years, I have tried all manner of alternative medications, very high (and potentially dangerous) NSAID’S, these in combination with, for example, Paracetamol taken 4th hourly and regularly, to absolutely zero noticeable effect.
    Those that insist that opiods have no place in non-cancer pain issues are quite simply wrong. Not only do they work, certainly well enough to take the ‘top edge ‘ of the pain away, but nothing else I have found has worked even moderately to bring the same manageable life type relief that they do. My own regimen is by and large one of using sustained release opiods, with the seldom used more rapid release for severe breakthrough pain.
    I take great exception to ‘specialists’, eg anaesthetic consultants telling me how poorly these medicines work, and how inappropriate they are for my pain – of course, they declare this without offering anything that will actually work. I should make mention that it is no bowl of cherries being on.opiates at higher doses, or at all, and the side effect profile is very unpleasant.
    Having reduced much higher doses over the years I know with certainty that I can and will come off the medication, but not until at least some of my pain is addressed via surgery I am awaiting – my dual disc lesion on my lower L back is inoperable, but I also have extreme pain in my R rib area, due to damage caused through a prior surgery.
    I am well aware of the dilemma that those like myself face – most GPs will no longer prescribe opiates, and I must travel 1 hour monthly to my former very supportive GP.
    It is often assumed that users have ill intent as regards their opiate medication, a function, sadly, of there being a large number that are abusing the drugs, or onselling them etc.
    It is wrong in the extreme to make such broad and bold statements that these drugs are of no use in the management of non cancerous type pain, at least until real alternatives can be found for very, very real & intractable pain. As much as I want to be rid of them, they must remain a very necessary evil for myself & many others who would not be able to effectively manage without them.

  3. CK says:

    I totally disagree with the findings. Back pain is not the only type of non-cancer pain as noted above.

    I attended a well regarded pain clinic as an outpatient of a large public hospital in Sydney for treatment for chronic peripheral neuropathic pain.

    I am a 24/7 solo carer of a child with multiple disabilities whom I home-school.

    My experience of the so called pain clinic was one of uselessness. They DID NOT acknowledge my situation, could not alter their program in any way in order to assist me as a carer (which is discriminatory) and utterly failed me as a human being. Asking a person who can barely put their feet on the ground to walk 1km per day is just laughable, if it were not serious! Telling me they can’t help me until I stop being a carer (ummm… what exactly am I to do with my son??) after waiting for 2 years just to see these overpaid time wasters!!!

    Am I angry? Damn right I am! Are they clueless? Damn right they are!

    Is it no wonder we seek CBD?

  4. Scott masters says:

    I agree with Dr Dawda that primary care, with assistance could assist tremendously in this field. If all the PHC’a around Australia came on board with this some tremendous health care improvements and economic savings could be made. The public hospitals will not be and have not been a sustainable model to manage the vast amount of persistent pain patients the exist in our population.

Leave a Reply

Your email address will not be published. Required fields are marked *