Is opioid withdrawal necessary within comprehensive pain rehabilitation programs?

Abstract

1. IntroductionOpioid use in the treatment of chronic pain is controversial,with multiple perspectives having been voiced over the past fewdecades. Opioids have long been viewed critically from the per-spective of comprehensive pain rehabilitation programs (CPRPs),which utilize the expertise of a team of providers to enhance effec-tive functioning even with continuing pain [15]. Principally, theseconcerns center around findings that opioid use can be associatedwith greater functional impairment and disability [9,10,20], whichis obviously contrary to the pursuit of effective rehabilitation.The early CPRPs, chiefly reported by Fordyce and colleagues,specifically highlighted the role of problematic opioid use as amaintaining factor in disability, and made use of operant methodsto decrease consumption when deemed necessary for therapeuticbenefit (eg, [13,27]). Contemporary programs have taken a varietyof approaches with regard to opioid use, with some requiring man-datory opioid withdrawal for all patients. It is not clear, however,that mandatory withdrawal is necessary for improvement, an issueexamined in detail within the present review. In particular, wesought to analyze whether opioid use was indeed a risk to treat-ment outcomes following CPRP and to identify any characteristicsof opioiduse thatwere particularly problematic.We also examinedthe effects of mandatory opioid withdrawal on CPRP outcomes.2. Is any pretreatment opioid use a risk to treatment outcomes?There are now several studies that provide data concerningwhether individuals using opioids at treatment onset achievepoorer outcomes in comparison to those who are not. The mostcommon finding indicates no difference in treatment outcome,although there is some variability across studies and specificmeasures.For example, 3 articles from a group of authors based at theMayo Clinic in the United States [16,24,26] have examined differ-ences in outcome following a 3-week outpatient CPRP incorporat-ing mandatory opioid withdrawal. In total, these articles include888 patients admitted to treatment. All 3 studies reported signifi-cant improvements across measures of emotional, physical, andsocial functioning regardless of pretreatment opioid use status.Additionally, rates of successful withdrawal from opioids werehigh, with between 92.6% and 97.8% of patients off all opioids attreatment conclusion. Two studies found no differences in out-comes immediately following treatment based on pretreatmentopioid use [16,26], with one also reporting an absence ofdifferences at a 6-month follow-up [26]. The third study found dif-ferences in posttreatment outcome for pain intensity and catastro-phizing only, with no differences indicated for pain interference,perceived life control, depression/affective distress, or generalactivity level [24]. Further, the opioid-using group in this latterstudy reported significantly higher catastrophizing and pain attreatmentonset, whichmaypartially explainthe observed discrep-ancy in outcomes on these 2 measures.Kidner et al. [20] performed an investigation that was fairlysimilar in methodology to the studies of the Mayo Clinic group,including mandatory opioid withdrawal, although they also ex-panded the analyses by includingposttreatmentand 12-monthfol-low-up occupational and health care use data. The results of theuse/nonuse analyses were similar to those obtained by the MayoClinic group, with no differences in outcome across most measures,including depression, mental and physical health, and the MillionVisual Analog Scale [23]. There were fairly modest differences inpain intensity and the Oswestry Disability Index [8], with the non-opioid use group having lower scores in these 2 measures. Therewere differences in 1-year return-to-work rates in favor of thenon-opioid-using group, although these were modest as well(94% vs 88%). More pronounced differences, again in favor of thenon-opioid using group, were present for work retention, definedas being employed on the date of the 12-month follow-up assess-ment (85% vs 69%), and the proportion of patients who werereceiving pain treatment from a new provider (14% vs 30%). Therewere no differences at 1-year follow-up in rates of surgery, new in-jury, US worker’s compensation case settlement, or additionalwage or disability replacement.To our knowledge, only a single study has explicitly examinedthe effects of continued opioid use on outcomes. This study in-cluded146patients treatedwithin a CPRPnot requiring mandatoryopioid withdrawal [21]. Approximately half of the study partici-pants (55.1%) were taking opioids at treatment onset and only aminority of these had discontinued opioid use completely by theend of treatment (14.3% of users). As with other studies, a main ef-fect of treatment was found across all outcomes. No differenceswere indicated based on opioid use at discharge, including painseverity, depression, disability, or performance on a floor-to-waist