Opioid Taper Study
Study Details
Study Description
Brief Summary
The purpose of this study is to determine the effect of opioid taper on pain sensitivity in patients with chronic pain. In a well-characterized sample of men and women with chronic neuropathic pain on high-dose opioid therapy, experimental pain responses (cold-pressor, quantitative sensory testing) will be serially described over the course of and following an individualized opioid taper. In addition, functional improvements and subject-level predictors of response will be described.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Detailed Description
The overall Specific Aim of this proposal is to determine the effect of opioid taper on pain sensitivity in patients with chronic pain. Specifically, in a well-characterized sample of men and women with chronic neuropathic pain and receiving high-dose opioid therapy (>100mg morphine equivalents/day [MED]), experimental pain responses will be serially described over the course of an individualized opioid taper to a safer dose of 90mg MED for up to 12 months. Changes will be inspected within-subject over time, and pain perception will be measured with two valid and reliable experimental pain induction techniques commonly used to measure OIH (cold-pressor, quantitative sensory testing); in addition, related functional improvements and subject-level predictors of response will be described.
Hypothesis 1. Subjects undergoing opioid taper will have improved pain responses over time compared to within-subject baseline as measured by cold-pressor and quantitative sensory pain testing.
Hypothesis 2. Improvements in experimental pain responses will be positively related to improved functional outcomes compared to within-subject baseline as measured by the PROMIS physical, mental and social health measures.
Hypothesis 3. Degree of improvement in experimental pain responses related to opioid taper will be predicted by demographic, pain, and opioid use history characteristics of the subject.
Data showing that pain perception improves as opioids are withdrawn would provide an evidence-based, mechanistic rationale for opioid taper in patients with chronic pain and have the potential to support a sea-change in opioid prescription practices. In that ongoing opioid therapy brings with it significant health risks for the patient and the community, it is critical that empirical evidence of its efficacy be demonstrated to balance the benefits with the risks of adverse events, potential misuse and abuse, and patient safety.
Study Design
Outcome Measures
Primary Outcome Measures
- Pain Perception Measured Using the Cold-pressor Test (CPT) [up to one year (length of taper individualized and varies)]
Pain perception will be measured using the cold-pressor test (CPT) employing procedures consistent with those described in the literature. Order of pain testing will vary, and three aspects of the pain response will be captured at each study session: evoked pain; temporal summation; and conditioned pain modulation, which map on to the hypothesized peripheral, spinal and supra-spinal mechanisms of OIH. Reported are cold-pressor pain tolerance prior to and following taper.
- Conditioned Pain Modulation Measured Using the Quantitative Sensory Testing (QST) [up to one year (individualized, variable taper length)]
Conditioned pain modulation will be measured using the quantitative sensory testing (QST) employing procedures consistent with those described in the literature to capture supra-spinal mechanisms of OIH. To detect conditioned modulation, the subject is asked to verbally report the severity of pain experienced on a visual analogue scale (0- no pain, 10-worst pain ever) to a three-second painful heat stimulus (47○C) delivered at 12-15 second intervals, in the presence or absence of the non-dominant limb being immerged in a cold-water bath (12○C). The reported value is the difference between the average of pain scores reported in the absence of vs. the presence of the counter-stimulation. Reported are changes in the conditioned pain modulation assay both prior to and following taper. Taper is individualized thus length of taper varies between subjects.
Eligibility Criteria
Criteria
Inclusion Criteria:
-
between ages of 21-70;
-
documented chronic neuropathic non-malignant pain condition of at least one year duration;
-
on >100mg/day MED for at least 6 months;
-
have fully engaged in all prescribed non-opioid pain management treatments;
-
willing to undergo prescribed opioid taper;
-
otherwise in good physical and mental health, or in the care of a physician who is willing to take responsibility for such treatment;
-
able to understand the purpose and instructions of the study, and provide informed consent as approved by the University of Pennsylvania IRB.
Exclusion Criteria:
-
meet diagnostic criteria for an active substance use disorder other than nicotine;
-
be acutely psychotic, severely depressed, and/or in need of inpatient psychiatric treatment,
-
have a neurological or psychiatric illness that would affect pain responses, including anxiety disorders;
-
have a history of heart disease, stroke, or a pacemaker or uncontrolled high blood pressure. Good cardiovascular health is stipulated to ensure subjects can tolerate the sympathetic nervous system responses associated with the pain induction procedures.
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Penn Pain Medicine Center Tuttleman Center | Philadelphia | Pennsylvania | United States | 19146 |
Sponsors and Collaborators
- University of Pennsylvania
- National Institute on Drug Abuse (NIDA)
- National Institutes of Health (NIH)
Investigators
- Principal Investigator: Margaret A Compton, RN, PhD, University of Pennsylvania
Study Documents (Full-Text)
More Information
Publications
- Dowell D, Haegerich TM. Changing the Conversation About Opioid Tapering. Ann Intern Med. 2017 Aug 1;167(3):208-209. doi: 10.7326/M17-1402. Epub 2017 Jul 11.
- Peles E, Schreiber S, Hetzroni T, Adelson M, Defrin R. The differential effect of methadone dose and of chronic pain on pain perception of former heroin addicts receiving methadone maintenance treatment. J Pain. 2011 Jan;12(1):41-50. doi: 10.1016/j.jpain.2010.04.009. Epub 2010 Jun 19.
- Wang H, Fischer C, Chen G, Weinsheimer N, Gantz S, Schiltenwolf M. Does long-term opioid therapy reduce pain sensitivity of patients with chronic low back pain? Evidence from quantitative sensory testing. Pain Physician. 2012 Jul;15(3 Suppl):ES135-43.
- 831447
- 1R21DA046364-01A1
Study Results
Participant Flow
| Recruitment Details | |
|---|---|
| Pre-assignment Detail |
| Arm/Group Title | Chronic Pain Patients Undergoing Opioid Taper |
|---|---|
| Arm/Group Description | Chronic pain patients undergoing an individualized opioid taper to a safer daily dose of opioid for up to one year. |
| Period Title: Overall Study | |
| STARTED | 7 |
| COMPLETED | 7 |
| NOT COMPLETED | 0 |
Baseline Characteristics
| Arm/Group Title | Chronic Pain Patients Undergoing Opioid Taper |
|---|---|
| Arm/Group Description | Chronic pain patients undergoing opioid taper |
| Overall Participants | 7 |
| Age (years) [Mean (Standard Deviation) ] | |
| Mean (Standard Deviation) [years] |
55
(15.49)
|
| Sex: Female, Male (Count of Participants) | |
| Female |
5
71.4%
|
| Male |
2
28.6%
|
| Race/Ethnicity, Customized (Count of Participants) | |
| White |
6
85.7%
|
| Other |
1
14.3%
|
| Region of Enrollment (Count of Participants) | |
| United States |
7
100%
|
| mg morphine equivalents/day or MME/day (daily morphine mg equivalents) [Mean (Standard Deviation) ] | |
| Mean (Standard Deviation) [daily morphine mg equivalents] |
291.85
(182.62)
|
Outcome Measures
| Title | Pain Perception Measured Using the Cold-pressor Test (CPT) |
|---|---|
| Description | Pain perception will be measured using the cold-pressor test (CPT) employing procedures consistent with those described in the literature. Order of pain testing will vary, and three aspects of the pain response will be captured at each study session: evoked pain; temporal summation; and conditioned pain modulation, which map on to the hypothesized peripheral, spinal and supra-spinal mechanisms of OIH. Reported are cold-pressor pain tolerance prior to and following taper. |
| Time Frame | up to one year (length of taper individualized and varies) |
Outcome Measure Data
| Analysis Population Description |
|---|
| [Not Specified] |
| Arm/Group Title | Chronic Pain Patients Undergoing Opioid Taper |
|---|---|
| Arm/Group Description | Chronic pain patients undergoing opioid taper |
| Measure Participants | 7 |
| pre taper pain tolerance (baseline) |
24.01
(20.63)
|
| post-taper pain tolerance (timeframe variable) |
42.02
(41.83)
|
| Title | Conditioned Pain Modulation Measured Using the Quantitative Sensory Testing (QST) |
|---|---|
| Description | Conditioned pain modulation will be measured using the quantitative sensory testing (QST) employing procedures consistent with those described in the literature to capture supra-spinal mechanisms of OIH. To detect conditioned modulation, the subject is asked to verbally report the severity of pain experienced on a visual analogue scale (0- no pain, 10-worst pain ever) to a three-second painful heat stimulus (47○C) delivered at 12-15 second intervals, in the presence or absence of the non-dominant limb being immerged in a cold-water bath (12○C). The reported value is the difference between the average of pain scores reported in the absence of vs. the presence of the counter-stimulation. Reported are changes in the conditioned pain modulation assay both prior to and following taper. Taper is individualized thus length of taper varies between subjects. |
| Time Frame | up to one year (individualized, variable taper length) |
Outcome Measure Data
| Analysis Population Description |
|---|
| [Not Specified] |
| Arm/Group Title | Chronic Pain Patients Undergoing Opioid Taper |
|---|---|
| Arm/Group Description | Chronic pain patients undergoing opioid taper |
| Measure Participants | 7 |
| pre-taper conditioned pain modulation (baseline) |
-0.14
(0.42)
|
| post taper conditioned pain modulation (individualized taper, thus time length varies) |
-0.40
(0.79)
|
Adverse Events
| Time Frame | up to 12 months | |
|---|---|---|
| Adverse Event Reporting Description | Subjects were carefully screened and excluded from participation if they had any risk factors putting them at risk for serious adverse events and mortality. Presence of adverse event s assessed on a biweekly basis. | |
| Arm/Group Title | Chronic Pain Patients Undergoing Opioid Taper | |
| Arm/Group Description | Chronic pain patients undergoing opioid taper | |
All Cause Mortality |
||
| Chronic Pain Patients Undergoing Opioid Taper | ||
| Affected / at Risk (%) | # Events | |
| Total | 0/7 (0%) | |
Serious Adverse Events |
||
| Chronic Pain Patients Undergoing Opioid Taper | ||
| Affected / at Risk (%) | # Events | |
| Total | 0/7 (0%) | |
Other (Not Including Serious) Adverse Events |
||
| Chronic Pain Patients Undergoing Opioid Taper | ||
| Affected / at Risk (%) | # Events | |
| Total | 0/7 (0%) | |
Limitations/Caveats
More Information
Certain Agreements
Principal Investigators are NOT employed by the organization sponsoring the study.
There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.
Results Point of Contact
| Name/Title | Peggy Compton |
|---|---|
| Organization | University of Pennsylvania |
| Phone | 2158986679 |
| pcompton@nursing.upenn.edu |
- 831447
- 1R21DA046364-01A1