Table 1.

Components of the Comprehensive Opioid Reduction Protocol for Rural Chronic Non-Cancer Pain Patients: Original Intervention and the Crossover Arm (n = 186)

Opioid Reduction Protocol During Original InterventionOpioid Reduction Protocol During Crossover Phase
Risk assessment including: high dose opioids (>90 MME); medical co-morbidities (sleep apnea, COPD, etc.); Psychiatric comorbidities and concurrent use of benzodiazepines or carisoprodol.Same
Intervene in high-risk cases: Naloxone co-prescribing if patient is over 50 MME: rapidly taper of carisoprodol; Immediately begin opioid or benzodiazepine taper for patients on both. (benzo cannot be stopped or tapered rapidly due to risk of seizures); assessing for OUD and referring for MAT.Same
Patient education provided via an 8-week psycho-educational support group, handouts, and provider counseling during individual appointments.Patient education provided via handouts and provider counseling during individual appointments: no educational support group
“Universal Precautions”: All patients received opioid agreement; random urine drug screens (UDS) and monthly checks of online, state-wide prescription drug monitoring program.Same
Treatment of psychiatric comorbidities (depression; anxiety; insomnia; PTSD; nicotine dependence).Same
Maximizing non-pharmacological pain treatments (physical therapy; osteopathic manual medicine; massage; acupuncture; transcutaneous electrical nerve stimulation (TENS); joint and trigger point injections.Same
Maximized non-opioid pharmacologic treatments where possible (NSAID; SNRI; TCA; Gabapentinoids; topical analgesics).Same
Goal to taper all patients under 90 MME and most under 50 MME. Not expected to stop opioids completely.Goal to taper all patient to the lower threshold of 30 MME or to stop opioids entirely
High-risk patients who refused to taper were referred to pain specialty for consideration of MATAutomatic referral to pain specialty for patient who: were on 90 MME or more; were on opioids and benzodiazepine; who had significant medical comorbidities (sleep apnea; COPD)
Completed over 2 yearsCompleted over 1 year
  • COPD, Chronic obstructive pulmonary disease; MME, Morphine Milligram Equivalents; OUD, Opioid Use Disorder; MAT, Medication-Assisted Therapy; PTSD, Post-traumatic Stress Disorder; NSAID, Nonsteroidal Anti-Inflammatory Drugs; SNRI, Serotonin-norepinephrine Reuptake Inhibitors; TCA, Tricyclic Antidepressants.