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 Intervention | Opioid 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 MAT | Automatic 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 years | Completed 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.