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29/05/2019
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A multi-modal intervention programme for opioid reduction – design, delivery and lessons learnt so far
Dr Harbinder Sandhu
This project was funded by the National Institute for Health Research, Health Technology Assessment (project number 14/224/04). The views and opinions expressed
therein are those of the authors and do not necessarily reflect those of the HTA, NIHR, NHS or the Department of Health.
This project was funded by the National Institute for Health Research, Health Technology Assessment (project
number 14/224/04). The views and opinions expressed therein are those of the authors and do not necessarily
reflect those of the HTA, NIHR, NHS or the Department of Health.
Opioid Prescribing in the UK
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Percentage of each opioid prescribed in equivalent mg morphine in England from August 2010 to
February 2014.
Luke Mordecai et al. Br J Gen Pract 2018;68:e225-e233
©2018 by British Journal of General Practice
Variation in English CCGs in opioid prescribing in
equivalent mg of morphine from August 2010 to
February 2014.
Luke Mordecai et al. Br J Gen Pract
2018;68:e225-e233
©2018 by British Journal of General Practice
Shared variance explained by; Latitude = 66% Social deprivation =33%
Pain and Opioids: A North South Divide ?
Prevalence of Chronic Pain by Local Authority and Region
Opioid Use by Pain Grade North vs South
Patients are 8 times more likely to receive an opioid prescription in NE compared to London
©2018 by British Medical Journal Publishing Group
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Opioids: Do We Have a North East Problem?
Todd, A., et al. (2018). "The Pain Divide: a cross-sectional analysis of chronic pain prevalence, pain intensity and opioid utilisation in England." BMJ Open 8(7): e023391.
How can we help people reduce and taper of their Opioids?
Solutions to the Opioid Problem
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Sandhu, H., et al. (2018). "What interventions are effective to taper opioids in patients with chronic pain?" Bmj 362: k2990.
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Opioid reduction Interventions
• Interdisciplinary programmes
• Buprenorphine assisted dose reduction
• CBT interventions
• Inpatient detoxification
• Ketamine assisted dose reduction
• Acupuncture and electroacupuncture
• Mindfulness
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Frank JW, Lovejoy TI, Becker WC, etal . Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Ann Intern Med 2017;167:181-91. 10.7326/M17-0598 28715848
Opioid reduction the evidence • 11 RCTs
• 56 observational studies
• Quality
– Small Studies
– Heterogenous populations, interventions and outcome measures
– Not adequately powered to detect meaningful difference in opioid use
• Opioid tapering does not result in increase in pain (no or modest drop in VAS)
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• CI: Harbinder Sandhu (Warwick CTU)
• CI: Sam Eldabe (South Tees NHSFT)
Improving the Wellbeing of Opioid Treated Chronic pain
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To test the effectiveness and cost effectiveness of a patient-
centred multicomponent self-management intervention targeting
withdrawal of strong opioids on activities of daily living for people
living with chronic non-malignant pain.
Primary Objective
Inclusion Criteria
• Adults living with:
• chronic non-malignant pain
AND
• prescribed strong opioids for three months or more
AND
• Taken on most days in the last month
• Not housebound
• Able to interact in group activities
• Fluent in English
• Willingness for GP to be informed
Exclusion Criteria
• Regular use of injected opioid drugs
• Report chronic headache as the dominant painful disorder
• Serious mental health problems that preclude participation in
a group intervention
• Using opioids for malignant pain
• Unable to attend group sessions
• Previous entry or randomisation in the present trial.
• Participation in a clinical trial of an investigational medicinal
product in the last 90 days.
• Pregnancy
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Outcome Measures
• Activities of Daily Living • PROMIS Pain Interference Short Form (8A)
• Opioid use • Morphine equivalent use /day
• Other outcomes • Pain severity: (PROMIS Pain Intensity Short-Form (3A)) • Opioid withdrawal: Short Opioid Withdrawal Scale (ShOWS) • HRQoL (EQ-5D, SF12 V2) • Sleep quality: (Pittsburgh Sleep Quality Index) • Emotional well being: (Hospital Anxiety and Depression Scale) • Self efficacy: (Pain Self Efficacy Questionnaire) • Resource use: (GP records)
I-WOTCH baseline Opioid usage
Morphine Equivalent mg
Percentage
0-29 52%
30-59 15%
60-89 9%
90-119 6%
120-149 5%
150+ 12%
Recruitment: 608 participants randomised
Baseline data N=481
I-WOTCH Intervention Development
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Starting point: COPERS Intervention for self management of chronic pain
Patient and Public Involvement (PPI): Two meetings North East and North Cumbria Clinical Research Network
Two Lay advisors: members of the study team
Main learning points: Motivation to reduce opioids, barriers and facilitators to reducing opioids, structure and length of programme, topics to cover, facilitation, overall study design including “best usual care”
Intervention Development: Phase 1
Taylor SJ, Carnes D, Homer K, Kahan BC, Hounsome N, Eldridge S, et al. Novel Three-Day, Community-Based, Nonpharmacological Group Intervention for Chronic Musculoskeletal Pain (COPERS): A Randomised Clinical Trial. 2016;13(6):e1002040
Clinical Commissioning Group (Hambleton, Richmond and Whitby)
Further feedback: topics covered in day one and two of programme, pacing activities, goal setting
Feeling empowered and confident
Opioid education important
Handouts useful
Perceptions vs reality (lecturing – Interactive)
Phase 2: Pilot in the North East (UK)
N = 36 randomised
2 x groups delivered
Practicalities of delivering the intervention training (Using role play worked well and more interaction and cases)
Participants may be interviewed as part of the qualitative study
Phase 3: I-WOTCH pilot
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Theoretical Framework
Social Learning Theory
Self Efficacy
Group Based Behaviour Change Interventions
Behaviour Change
Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science : IS, 6, 42. doi:10.1186/1748-5908-6-42
The COM-B system - a framework for understanding behaviour
Theoretical Frameworks and Process
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Lessons Learned
I-WOTCH Intervention
Key components of group sessions
Opioid specific topics include: General pain management
topics include:
The rationale of prescribing in chronic pain Opioid induced tolerance and need for dose escalation Evidence of usefulness of opioids short and long term Side effects of opioids short term and long term Case studies of successful discontinued opioid therapy Opioid withdrawal symptoms Advantages of slow supervised taper Symptom management during tapering Pain control after opioids
Acute versus Chronic pain Coping and pacing skills Posture and movement advice Communication Skills Relaxation techniques Mindfulness
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Overview: I-WOTCH Intervention
• Manualised 3 Day Group Intervention.
• Delivered by lay person and nurse (specific intervention training)
• Day 1 (pain and drugs in context)
• Mind Mood and opioids
• Opioids Pros and Cons
• Pain Cycle and Breaking out
• Day 2 (Making Changes)
• Problem solving, goal setting and action planning
• Barriers to change unhelpful thinking
• Pacing
• Devise and Agree withdrawal plan with nurse
Overview: I-WOTCH Intervention
• Day 3 (Communication and relationships)
• Communicating with healthcare professionals
• Communication and listening skills
• Managing anger, frustration and irritability
• Recognising depression
• Practicing non drug pain management techniques
• Follow up
• Two one to one nurse telephone consultations
• One face to face consultation
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My Opioid Manager (Anglicised): Self help Booklet – Andrea Furlan and Amy Robidas (Toronto Rehabilitation Institute)
Relaxation CD
Control Intervention
Motivational Interviewing
Reflection of key topics which have been covered in the Group programmes
Goal setting
Addressing concerns
Offering support
Generating plan
One to One Consultations
• Bespoke built android app that creates tapering plans
• Reduction of 10% of starting dose each week until 30% is reached
• Then of that 30%, reduced by a further 10% weekly until the participant reaches zero
• The 10% figure may be rounded up to suit prescribing
• Fentanyl patches tapered in decrement of 12 mcg/hr patches then change to equianalgesic oral preparation
• Buprenorphine patches weaned using decreasing decrements of the patches with no substitution due to its agonist/ antagonist action
• Taper one drug at a time
• Specialist advice pregnant
-
Tapering Plans
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Tapering APP
3 day training for clinical facilitators
2 day training for Lay facilitators
Observations of sessions:
30 Competencies: Verbal and non-verbal communication, facilitation skills and group behaviour
Course Delivery: Pain education, opioid education, acceptance, withdrawal symptoms and identifying barriers to change.
Reflection and feedback:
Training and Quality Assurance
Input from patient and public involvement
Group support
One to one ongoing support valuable
Use of case studies and examples (successful tapering and complete withdrawal of opioids)
Facilitator training to be interactive as possible (allow practice)
Monitoring and support for facilitators whilst delivering and intervention and tapering
Reflection and feedback
Key Learning points
