Behavioral support does not improve patient-directed opioid tapering success

1. In this randomized clinical trial, adding cognitive behavioural therapy (CBT) or self-management support to patient-centered opioid tapering did not improve taper success at 12 months.

2. However, CBT was associated with fewer adverse events, including opioid withdrawal symptoms, compared with tapering alone.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Guidelines across multiple countries recommend opioid tapering using flexible, patient-centered approaches, which may improve outcomes related to comorbid mental health conditions. However, evidence regarding long-term opioid tapering remains limited, particularly with respect to tapering strategies, patient experience, and comparative effectiveness. This study compared two evidence-based behavioral pain management interventions—tapering combined with group cognitive behavioural therapy for chronic pain (pain-CBT) and tapering combined with a peer-led chronic pain self-management program (CSPMP)—against tapering alone without behavioral support. Across all three groups, taper success rates were similar, ranging from approximately 45% to 51%. The addition of pain-CBT or CSPMP did not significantly improve taper success and showed a non-significant trend toward lower success rates. However, participants in the pain-CBT group reported fewer adverse events. Specifically, pain-CBT was associated with a 54% reduction in opioid withdrawal symptoms and a 52% reduction in overall adverse events compared with tapering alone. These findings were consistent across subgroup and sensitivity analyses. The study has several limitations, including reduced sample size and unequal group allocation due to the COVID-19 pandemic, low attendance in behavioral interventions, and reliance on self-reported opioid use and pain outcomes, which may introduce bias. Despite these limitations, the findings suggest that while adding behavioral interventions such as pain-CBT or peer-led self-management does not improve tapering success rates, pain-CBT may meaningfully improve the tapering experience by reducing withdrawal symptoms and other adverse effects.

Click to read this study in AIM

Relevant Reading: Reducing Opioid Use for Chronic Pain With a Group-Based Intervention

In-Depth [randomized controlled trial]: This randomized clinical trial compared the effectiveness of opioid tapering alone versus tapering combined with two behavioral interventions: group cognitive behavioural therapy for chronic pain (pain-CBT) and a peer-led chronic pain self-management program (CSPMP). Participants were recruited from primary care and pain clinics across five US states. Eligible participants were aged 18-85 years, had chronic pain lasting at least 6 months, and were receiving prescription opioids at a dose of ≥10 morphine equivalent daily dose (MEDD) for at least 3 months. Patients were excluded if pregnant, cognitively impaired, non-English speaking, or diagnosed with moderate to severe opioid use disorder. Patients with other substance use disorders were not excluded and could continue usual pain and psychological care. A total of 562 participants were randomized to taper only (n = 191), taper plus pain-CBT (n = 203), or taper plus CSPMP (n = 168). Participants were predominantly female (53%), White (77%), and had low rates of substance dependence (99%). Mean age was 58 years (standard deviation [SD], 13), with mean duration of pain of 16.4 years (SD, 11.3) and opioid use of 12.4 years (SD, 9.8). Overall attrition was 16%. Taper success rates were similar across groups: 50.9% in taper only, 48.6% in taper plus pain-CBT, and 44.5% in taper plus CSPMP. Compared with taper alone, differences in success were not statistically significant for either intervention. However, taper plus pain-CBT was associated with a 54% reduction in opioid withdrawal symptoms and a 52% reduction in overall study-related adverse events. CSPMP did not demonstrate similar reductions. Subgroup and sensitivity analyses were consistent with primary findings, though taper success appeared higher among men and participants aged ≤60 years in the taper-only group. Overall, adding behavioral interventions did not improve taper success rates, but pain-CBT was associated with a substantially improved tapering experience through fewer withdrawal symptoms and adverse events.

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