This is the first update of the original Cochrane Review published in 2013. The conclusions
of this review have not changed from the 2013 publication. People with chronic non‐cancer
pain who are prescribed and are taking opioids can have a history of long‐term, high‐dose
opioid use without effective pain relief. In those without good pain relief, reduction
of prescribed opioid dose may be the desired and shared goal of both patient and clinician.
Simple, unsupervised reduction of opioid use is clinically challenging, and very difficult
to achieve and maintain. To investigate the effectiveness of different methods designed
to achieve reduction or cessation of prescribed opioid use for the management of chronic
non‐cancer pain in adults compared to controls. For this update we searched CENTRAL,
MEDLINE, and Embase in January 2017, as well as bibliographies and citation searches
of included studies. We also searched one trial registry for ongoing trials. Included
studies had to be randomised controlled trials comparing opioid users receiving an
intervention with a control group receiving treatment as usual, active control, or
placebo. The aim of the study had to include a treatment goal of dose reduction or
cessation of opioid medication. Two review authors independently extracted data and
assessed risk of bias. We sought data relating to prescribed opioid use, adverse events
of opioid reduction, pain, and psychological and physical function. We planned to
assess the certainty of the evidence using the GRADE approach, however, due to the
heterogeneity of studies, we were unable to combine outcomes in a meta‐analysis and
therefore we did not assess the evidence with GRADE. Three studies are new to this
update, resulting in five included studies in total (278 participants). Participants
were primarily women (mean age 49.63 years, SD = 11.74) with different chronic pain
conditions. We judged the studies too heterogeneous to pool data in a meta‐analysis,
so we have summarised the results from each study qualitatively. The studies included
acupuncture, mindfulness, and cognitive behavioral therapy interventions aimed at
reducing opioid consumption, misuse of opioids, or maintenance of chronic pain management
treatments. We found mixed results from the studies. Three of the five studies reported
opioid consumption at post‐treatment and follow‐up. Two studies that delivered 'Mindfulness‐Oriented
Recovery Enhancement' or 'Therapeutic Interactive Voice Response' found a significant
difference between groups at post‐treatment and follow‐up in opioid consumption. The
remaining study found reduction in opioid consumption in both treatment and control
groups, and between‐group differences were not significant. Three studies reported
adverse events related to the study and two studies did not have study‐related adverse
events. We also found mixed findings for pain intensity and physical functioning.
The interventions did not show between‐group differences for psychological functioning
across all studies. Overall, the risk of bias was mixed across studies. All studies
included sample sizes of fewer than 100 and so we judged all studies as high risk
of bias for that category. There is no evidence for the efficacy or safety of methods
for reducing prescribed opioid use in chronic pain. There is a small number of randomised
controlled trials investigating opioid reduction, which means our conclusions are
limited regarding the benefit of psychological, pharmacological, or other types of
interventions for people with chronic pain trying to reduce their opioid consumption.
The findings to date are mixed: there were reductions in opioid consumption after
intervention, and often in control groups too. Reducing prescribed opioid use in adults
with chronic non‐cancer pain Bottom line Based on the available evidence, we do not
know the best method of reducing opioids in adults with chronic pain conditions. We
found mixed results from a small number of studies included in this review. Background
This is an updated review. The first review was published in 2013. About one in five
adults suffer from moderate or severe chronic pain that is not caused by cancer. Some
people with this type of pain are treated with opioids (typically with drugs such
as morphine, codeine, oxycodone, fentanyl, or buprenorphine, either as tablets or
as patches placed on the skin). It is not unusual for this medication to be ineffective
or to stop working over time, and, sometimes, effective pain relief is not achieved
despite doses being increased. Stopping using opioid drugs is not easy, especially
when they have been used for some time, because stopping abruptly can cause unpleasant
side effects.This review looked for high‐quality studies (randomised controlled trials)
of treatments to help adults safely stop taking opioids prescribed for their pain.
Study characteristics We searched for studies up to January 2017. We found five studies,
and they investigated 278 people. Most people included in the studies were women,
who were around 50 years of age, and reported a mixture of chronic pain conditions
(e.g. headache, back pain, muscle pain). The studies included acupuncture, mindfulness,
and cognitive behavioral therapy as strategies to decrease the amount of opioids taken
by adults with chronic pain. Key results No conclusions can be drawn from this small
amount of information. Therefore, it is not clear whether these treatments decrease
the amount of opioids in adults with chronic pain (primary outcome) or reduce pain
intensity, physical ability or mood (secondary outcomes). Three studies did include
negative effects of their treatment, and two reported that the participants did not
have anything negative happen to them because of the trial they were in. Non‐randomised
studies, not included in this review, do indicate that for many people intensive rehabilitation
packages may bring about major reduction in opioid use. Reducing prescribed opioid
use in chronic non‐cancer pain is an important topic in need of more systematic research.
Quality of the evidence We were not able to judge the quality of evidence included
in this review because the studies were so different and could not be combined.