Effect of Opioid Use on Exercise-Based Motivational Interviewing for Fibromyalgia

Among patients with fibromyalgia, motivational interviewing (MI) to promote physical exercise improved physical function and fibromyalgia (FM) symptoms in opioid nonusers but not in opioid users, according to a study published in The Journal of Rheumatology.

“Exercise is an important component in the management of FM. Given that FM is a chronic condition, exercise has to be sustained long term,” Dennis C. Ang, MD, MS, of Wake Forest School of Medicine, told Clinical Pain Advisor. 

MI is a method of counseling that aims to help patients address uncertainties about changing their behavior and reinforce their motivation to change.¹ This approach has been shown to improve rates of smoking cessation, medication adherence, and exercise participation.^1-3

In the Research to Encourage Exercise for Fibromyalgia trial (REEF, Clinicaltrials.gov Identifier: NCT00573612), Dr Ang and colleagues found that FM patients receiving MI had lower severity of global FM symptoms and increased physical activity than FM patients randomized to FM self-management.⁴ However, these effects were not sustained at 6 months.⁴

Dr Ang suggested that opioid use may have been a contributing factor to the lack of sustained efficacy of MI in REEF. “Because opioids may cause cognitive impairment, psychoeducational treatment intervention such as MI may be less effective among opioid users,” he said.

In the current study, Dr Ang and colleagues performed a secondary analysis of the REEF trial that assessed the efficacy of MI in FM patients in the subsets of opioid users and nonopioid users.⁵

A total of 107 patients received 6 phone-based MI sessions and 109 patients received 6 sessions of FM self-management lessons (attention control [AC]) over a period of 12 weeks. The primary outcomes were changes in pain severity, global FM symptom severity, physical function, and amount of light-to-moderate physical activity (LMPA) from baseline to follow-up at 12 weeks, 24 weeks, and 36 weeks.⁵

The proportion of patients taking opioids was similar in the MI and AC groups (32.7% vs 33.0%). Among opioid nonusers, significantly more patients receiving MI had increased physical function and LMPA and reduced pain severity and global FM severity at 6 months compared with AC patients. However, among opioid users, no differences in the primary outcomes were observed between the MI and AC groups.⁵

“In this secondary data analysis, it appears that opioid use diluted the beneficial effects of MI in improving exercise adherence long term,” Dr Ang concluded.

According to Dr Ang, these study results may help guide treatment decisions in FM. “In today’s world of cost-conscious healthcare delivery, it is important to precisely predict treatment effect and tailor treatment to maximize efficacy,” he said. “Clinicians may consider offering exercise-based MI to patients who are not taking opioids to enhance FM-related treatment outcomes.”

Summary and Clinical Applicability

In the REEF trial, MI to promote exercise increased physical activity and reduced the severity of pain and global FM symptoms among patients with FM. However, these benefits were not sustained at 6 months.⁴ Dr Ang and colleagues hypothesized that opioid use may have been a contributing factor to the lack of long-term efficacy.⁵

In this secondary analysis of the REEF trial, the benefits of MI were compared with those of AC among the subsets of opioid users and opioid nonusers. “Exercise-based MI was associated with sustained clinical benefits 6 months after completion of therapy, but only for those who were not taking opioids,” the authors wrote.⁵

Limitations and Disclosures

• The study results were derived from a post-hoc analysis of the REEF trial and may be subject to Type1 or Type 2 error; therefore, definitive conclusions cannot be made on the basis of these data
• Opioid use status was determined by self-report at study entry
• No differentiation was made between acute use and chronic use of opioids among opioid users

The authors report no relevant disclosures.

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References

1. Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2015;(3):CD006936. doi: 10.1002/14651858.CD006936.pub3.
2. Palacio A, Garay D, Langer B, et al. Motivational interviewing improves medication adherence: a systematic review and meta-analysis. J Gen Intern Med. 2016;31(8):929-40. doi: 10.1007/s11606-016-3685-3.
3. O’Halloran PD, Blackstock F, Shields N, et al. Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis. Clin Rehabil. 2014;28(12):1159-71. doi: 10.1177/0269215514536210.
4. Ang DC, Kaleth AS, Bigatti S, et al. Research to encourage exercise for fibromyalgia (REEF): use of motivational interviewing, outcomes from a randomized-controlled trial. Clin J Pain. 2013;29(4):296-304. doi: 10.1097/AJP.0b013e318254ac76.
5. Kim S, Slaven JE, Ang DC. Sustained Benefits of Exercise-based Motivational Interviewing, but Only among Nonusers of Opioids in Patients with Fibromyalgia. J Rheumatol. 2016. pii: jrheum.161003.