Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Jul 27;15(7):e0236419.
doi: 10.1371/journal.pone.0236419. eCollection 2020.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

Abhimanyu Sud  1 , Alana Armas  2 , Heather Cunningham  3 , Shawn Tracy  2 , Kirk Foat  4 , Navindra Persaud  5   6 , Fardous Hosseiny  7 , Sylvia Hyland  8 , Leyna Lowe  7 , Erin Zlahtic  9 , Rhea Murti  10 , Hannah Derue  11 , Ilana Birnbaum  12 , Katija Bonin  12 , Ross Upshur  2   13 , Michelle L A Nelson  2   14
Affiliations

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

Abhimanyu Sud et al. PLoS One. .

Abstract

Context: Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined.

Objective: Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit.

Study design: Systematic rapid realist review.

Dataset: Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation.

Results: 95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion.

Conclusions: Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

PubMed Disclaimer

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. PRISMA flow diagram.
Fig 2
Fig 2. Included studies by decade.
Fig 3
Fig 3. Time of last outcome measurement.
Fig 4
Fig 4. Programs’ opioid tapering protocols.
Fig 5
Fig 5. Summary of the logic and design of MDC programs.
See this image and copyright information in PMC

References

    1. Centers for Disease Control and Prevention. Drug overdose deaths: Centers for Disease Control and Prevention 2019 [cited 2019].
    1. Leifman H. Drug-related deaths in Sweden: Estimations of trends, effects of changes in recording practices and studies of drug patterns. Stockholm: Centralförbundet för alcohol-och narkotikaupplysning, 2016. Contract No.: Rapport 158.
    1. Ho J. The contemporary American drug overdose epidemic in international perspective. Popul Dev Rev. 2019;45(1):7–40. 10.1111/padr.12228 - DOI - PMC - PubMed
    1. Ontario Agency of Health Protection and Promotion (Public Health Ontario), Office of the Chief Coroner, Ontario Forensic Pathology Service, Ontario Drug Policy Research Network. Opioid mortality surveillance report: Analysis of opioid-related deaths in Ontario July 2017—June 2018 Toronto, ON: 2019.
    1. Gomes T, Khuu W, Martins D, Tadrous M, Mamdani M, Paterson J, et al. Contributions of prescribed and non-prescribed opioids to opioid related deaths: Population based cohort study in Ontario, Canada. BMJ. 2018;362. - PMC - PubMed

Publication types

Substances

Grants and funding