Online E-health Program Reduces Daily Opioid Use, Improves Pain Scores vs Usual Care

Among patients with chronic pain receiving long-term opioid treatment, use of an online chronic pain program (e-health) compared with usual treatment was associated with a statistically significant reduction in daily use of opioid analgesics and with a greater decrease in pain intensity, according to a study published online April 3, 2023, in the journal Pain.

Specifically, more than half (53.6%) of participants in the study’s e-health arm were able to reduce daily opioid medications by ≥15% after 6 months compared with 42.3% of participants in the control group, report investigators at Washington State University. Furhter, more than twice the proportion of those in the e-health group vs the usual care group (14.5% vs 6.8%) achieved a ≥2 point reduction in pain intensity, considered to be a clinically meaningful outcome.

E-health intervention group participants also demonstrated increases in knowledge of pain, confidence in pain self-management, and coping skills.

The body of evidence in support of the efficacy of self-management programs to reduce pain intensity and minimize related disability is robust, note study authors, led by WSU associate professor of nursing Marian Wilson. They add, however, that few large-scale evaluations of online pain self-management programs have been conducted that capture the effects on reducing use of opioids (in morphine equivalent dose [MED]) in addfition to pain outcomes.

To help address the gap, Wilson and fellow WSU investigators, evaluated the Goalistics Chronic Pain Management Program (e-health) for its effect on long-term opioid therapy (LOT) dose.

Eligible participants were adult (aged 25-80 years) outpatients with mixed chronic pain conditions treated at primary care and pain clinics at 2 US academic health care systems. Inclusion criteria were having been prescribed LOT of ≥20 morphine equivalent dose over the 90 days prior to enrollment (from February 2018 to October 2020), having ≥1 chronic pain-related diagnosis, and a Brief Pain Inventory (BPI) score of ≥3.

All participants received LOT-prescriber-provided treatment of MED ≥20 mg and were randomized 1:1 to either continue with that regimen as treatment as usual (TAU) alone or to also receive an e-health intervention (a 4-month subscription to the online Goalistics Chronic Pain Management Program).

The final cohort numbered 402 participants (mean age 56.7 years, 69.4% women); 62.2% were from primary care, the remainder from pain clinics. Participants reported an average of 3.8 pain diagnoses, the most common of which was arthritis (61.7%), followed by back (77.6%), and joint (58.2%) pain. The mean BPI intensity score was 5.9 and mean MED was 48.0 mg. Investigators randomized 200 participants to e-health and 202 to TAU. Participants completed self-report measures at baseline, at the end of the 4-month active treatment period, and at 10 months, ie, 6-months post-active treatment.

FINDINGS

When they assessed daily opioid use, Wilson et al found that of 196 participants in the e-heath arm, 105 (53.6%) achieved a ≥15% reduction in daily MED compared with 85 (42.3%) of 201 TAU participants (odds ratio, 1.6 [95% CI, 1.1-2.3]; P=.02). The number needed to treat (NNT) was 8.9 (95% CI, 4.8- 66.0).

Analysis of change in pain intensity measured at 6 months found 24 (14.5%) of 166 e-health participants achieved a ≥2 point decrease in BPI intensity vs 13 (6.8%) of 192 TAU participants (OR, 2.4 [95% CI, 1.2-4.9]; P=.02). Wilson and colleagues repoter further that a greater proportion of e-health participants (25.3%) vs TAU participants (16.7%), achieved a ≥2 point decrease in BPI interference score (OR, 1.7 [95% CI, 1.0-2.8]; P=.04).

Benefits were also observed in pain knowledge, pain self-efficacy, and pain coping with pain catastrophizing seeing the greatest improvement.

The authors propose several possible mechanisms for the MED reductions observed. Information provided to e-health participants on opioid tolerance, dependency, and overdose risks as well as on nonopioid pain management alternatives could have affected their receptivity to discussions about dose reduction already underway in many pain clinics. The increase observed in pain self-efficacy also may have contributed.

The Institute of Medicine in 2011 recommended pain self-management education as foundational to chronic pain care. Absent from those and subsequent recommendations, state Wilson et al, is how such education should be integrated into clinical practice and how it can best be delivered.

Internet-based programs, the authors point out, could allow for increased standardization and replication of such programs, as well as scaling to provide accessible and affordable resources to the significant proportion of the population with chronic pain. Regarding the current program, the authors state, “This low-burden online intervention could assist adults on LOT in reducing daily opioid use while self-managing pain symptoms."

Reference: Wilson M, Rowena D, Daniel L, et al. Opioid dose and pain effects of an online pain self-management program to augment usual care in adults with chronic pain: a multisite randomized clinical trial. J Pain. 2023;164:877-885. Published online April 3, 2023. doi:10.1097/j.pain.0000000000002785