Motivational Interviewing for Opioid Tapering

The following article features coverage from PAINWeek 2017 in Las Vegas, Nevada. Click here to read more of Clinical Pain Advisor‘s conference coverage.

LAS VEGAS – In a presentation he gave at PAINWeek, held September 5-9 in Las Vegas, Nevada, Ravi Prasad, PhD, clinical associate professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University in California, and associate chief of Pain Psychology in the pain medicine division there, focused on the role of behavioral treatment, particularly the use of motivational interviewing (MI) in tapering opioid medications.¹

“MI is a collaborative, goal-oriented style of communication with particular attention to the language of change,” said Dr Prasad. “It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion,” he added. MI processes include engaging with the patient to establish a connection, focusing on a particular goal or agenda, evoking the patient’s own motivation for change, and planning a specific course of action.

Basic interaction techniques used in MI are reflected in the acronym OARS: open questions, affirmations, reflective listening, and summarizing. Clinicians using MI should reinforce patients’ “change talk” regarding their desire (“I want to…”), ability (“I can…”), reasons (“I would probably feel better if…”), and need (“I have to…”) to change.

MI has been used in a range of treatment settings for various types of substance abuse, including opioids, and it has been linked to improved treatment engagement and outcomes, increased medication adherence, and decreased illicit drug use. In a recent pilot randomized controlled trial of a tapering support intervention that included MI, compared with usual care, reductions in opioid doses and pain severity ratings were observed for both groups, and MI led to improvements in pain interference and pain self-efficacy.²

The Stanford Comprehensive Interdisciplinary Pain Program is geared to patients with complex, chronic noncancer pain and comorbid psychiatric disorders or high levels of psychological distress. The program includes physical therapy, occupational therapy, medication optimization (most commonly in the form of opioid tapering), and lifestyle/behavioral modification. All team members reinforce behaviors such as self-management skills, increased activity levels, and a focus on functioning vs medication. Conversely, the center’s staff avoids reinforcing negative behaviors, such as pain behavior, inactivity, a focus on medication, and somatic complaints.

Among the 44 patients (25 women) who recently participated in the Stanford Comprehensive Interdisciplinary Pain Program, significant reductions in scores on the Center for Epidemiologic Study of Diseases–Depression Scale (P <.001), the McGill Pain Questionnaire (P =.005), and the McGill Pain Questionnaire-Visual-Analog Scale (P <.001) at the time of discharge vs admission were reported. In addition, significant changes were observed for multiple scales of the Profile of Mood States (POMS) test; for example, POMS Tension-Anxiety (P =.005), POMS Depression-Dejection (P =.001), and POMS Vigor-Activity (P =.005).

Findings regarding the effectiveness of other interdisciplinary programs for opioid cessation were also reviewed.^3,4 The following recommendations for addressing chronic pain in the context of substance use disorders were offered in closing: Use a “biopsychosocial formulation of the patient’s predicament versus focusing solely on a biomedical model,” and emphasize a “focus on function versus pain elimination.” The latter may include setting functional goals such as returning to work and the use of activity-tracking sheets.

References

1. Hah J, Prasad R. Crisis = opportunity: reducing medication burden while managing chronic pain. Presented at Pain Week 2017; September 5-9, 2017; Las Vegas, NV.
2. Sullivan MD, Turner JA, DiLodovico C, et al. Prescription opioid taper support for outpatients with chronic pain: a randomized controlled trial. J Pain. 2017;18(3):308-318.
3. Townsend CO, Kerkvliet JL, Bruce BK, et al. A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission. Pain. 2008; 140(1):177-89. doi:10.1016/j.pain.2008.08.005
4. Murphy JL, Clark ME, Banou E. Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment. Clin J Pain. 2013; 29(2):109-117. doi:10.1097/AJP.0b013e3182579935