Opioid reduction for patients with chronic pain in primary care: systematic review

Long-term opioid treatment in patients with chronic pain is often ineffective and possibly harmful. These patients are often managed by GPs who are calling for a clear overview of effective opioid reduction strategies for primary care.

To evaluate effectiveness of opioid reduction strategies applicable in primary care for patients with chronic pain on long-term opioid treatment.

Systematic review of controlled trials and cohort studies performed in primary care from inception date to 15 January 2021.

Literature search conducted in EMBASE, MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, Google Scholar, and PsycINFO. Studies evaluating opioid reduction interventions applicable in primary care among adults on long-term opioid treatment for chronic non-cancer pain were included. Risk of bias was assessed using the Cochrane risk-of-bias tool (version 2) (RoB 2) or the Risk of bias in non-randomized studies - of interventions (ROBINS-I) tool. Narrative synthesis was performed because of clinical heterogeneity in study designs and types of interventions.

In total, five randomised controlled trials (RCTs) and five cohort studies were included (N = 1717, range n = 35 to n = 985) exploring various opioid reduction strategies. Of these, six studies had high/critical RoB, three moderate RoB, and one low RoB. Three cohort studies: investigating a GP-supervised opioid taper (critical ROBINS-I), an integrative pain treatment (moderate ROBINS-I), and group medical visits (critical ROBINS-I) demonstrated significant between-group opioid reduction.

Results carefully point in the direction of a GP supervised tapering and multidisciplinary group therapeutic sessions to reduce long-term opioid treatment. However, because of high risk of bias and small sample sizes, no firm conclusions can be made demonstrating the need for more high-quality research.