This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Many people take opioids to relieve long-term pain not caused by cancer. But opioids can cause other health problems and be difficult to discontinue. Researchers found that, compared with usual care, a group-based intervention with one-to-one support for people on opioids:
- helped them discontinue their medication
- did not increase the impact of pain on everyday life.
From interviews with participants, the researchers provide suggestions to help increase the success of interventions to reduce opioid use.
More information about opioid use can be found on the NHS website.
The issue: how best to discontinue opioids?
NHS England states that opioid drugs (including morphine, tramadol and fentanyl), which are commonly used in end-of-life care, are also effective treatments for short-lived pain not caused by cancer.
However, these drugs have side effects and they are not recommended as treatments for long-term pain by the National Institute for Health and Care Excellence (NICE). Despite this, data collected by NHS England in January 2021 showed that more than 1 million people in England received opioids for more than 3 months.
In this study, researchers explored whether a group-based intervention could help people with long-term pain (not caused by cancer) reduce (taper) or stop their opioid treatment.
Did the intervention reduce opioid use?
The overall study included 608 adults from general practices across the England. They all had long-term pain (not caused by cancer) and had taken opioids on most days for at least 3 months. Participants were 61 years old on average; most (60%) were women and White British (96%).
Everyone in the study received enhanced usual care (a self-help booklet called My Opioid Manager and a relaxation CD). Half (305) received, in addition, the I-WOTCH programme. This consists of 3 day-long group sessions (delivered over 3 weeks) facilitated by a trained nurse and someone with lived experience of tapering opioids. The groups provided education about opioids, and covered pain self-management, motivation, and goals to reduce opioids. They included case studies of people who had successfully tapered their opioids.
People in the I-WOTCH group also had up to 4 one-to one-sessions with the nurse to work towards a shared decision to taper the opioids. Nurses provided support and individualised the tapering according to each person’s needs; tapering could be slowed and paused as required. Nurses used an app (developed as part of the research programme) to devise the individualised tapering plan; GPs signed off the plan with each participant.
Half the intervention group (144 people; 47%) attended the whole programme, with most (190 people; 62%) attending at least one group session plus a one-to-one session with a nurse. Most participants provided data on whether they were still taking opioids (433 people) and completed a questionnaire about how much pain interfered with their life (439 people).
After one year, people who received the intervention:
- were 4 times more likely to discontinue opioids (65/225; 29%) than the usual care group (15/208 people; 7%)
- had pain with similar impact on everyday life to the usual care group.
Few people (1%) who received the intervention needed additional medical care for possible opioid withdrawal symptoms (including shortness of breath, fever and pain). Serious side effects were slightly more common in the intervention than in the usual care group, but were often unrelated to the intervention.
How did the intervention help?
In a separate part of the project, researchers interviewed 40 study participants (20 from each group), plus 18 nurses and other facilitators of the intervention.
Interviewees stressed the complexity of living with long-term pain; many people have multiple health problems, and their lives revolve around their pain, pain relief, healthcare appointments and procedures.
People generally found the groups supportive and encouraging, and most ran smoothly. Some could be disrupted by group members.
Interviewees suggested that tapering is most likely to succeed when:
- the time is right; when someone is ready to taper, feels informed, motivated and confident
- support is available at all stages of tapering from family, GP or an intervention such as the educational group
- group interventions allow people to share information and skills in pain management, discuss and explore their fears and motivations.
Why is this important?
This study found that a group-based intervention increased the numbers of people who stopped taking opioids. It did not alter the impact of pain on their everyday life. People were generally positive about the educational groups, but fewer than half attended all sessions.
The research team notes that participants might have been more committed to reducing their opioids, than others. In addition, most of those who took part were White British. This means the findings might not apply to everyone taking long-term opioids.
What’s next?
The researchers are working with Integrated Care Boards in London to implement the I-WOTCH programme, with a view to a wider roll out.
The trial report won the European Society of Regional Anaesthesia and Pain Therapy Best Chronic Pain Paper Award in 2024. The cost-effectiveness analysis will be published soon.
You may be interested to read
This is a summary of Sandhu HK, and others. Reducing opioid use for chronic pain with a group-based intervention. A randomized clinical trial. Journal of the American Medical Association 2023; 329: 1745 – 1756.
and
Nichols VP, and others. 'It was a joint plan we worked out together'. How the I-WOTCH programme enabled people with chronic non-malignant pain to taper their opioids: a process evaluation. BMJ Open 2023; 13: e074603.
Sandhu HK, and others. Development and testing of an opioid tapering self-management intervention for chronic pain: I-WOTCH. BMJ Open 2022; 12: e053725.
Information about chronic pain can be found on the NHS website.
Funding: NIHR Heath Technology Assessment Commissioned Call.
Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the original paper.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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