Identifying recommendations for an opioid weaning intervention for Chronic Non-Cancer Pain patients: A mixed-method study

Chronic Non-Cancer Pain (CNCP) affects almost 20% of the UK’s population and has both individual and economic burdens. Opioids have been increasingly prescribed in primary care to help manage CNCP and given the inherent nature of chronic pain, are usually issued long term. Research over the last two decades has raised concerns regarding the efficacy of opioids for managing CNCP, and potential harm particularly in doses that exceed 120mg of Morphine Equivalent Dose (MED). There is an emerging public health priority therefore to reduce the risk of harm in those patients already established on high dose opioids. Opioid weaning has been recommended, however a caveat to this is the lack of evidence on how to best manage opioid withdrawal and patients’ continued experience of pain. This research sought to identify recommendations for an intervention designed to reduce high daily doses of opioids among CNCP patients in primary care. To achieve this the research investigated high dose opioid prescribing in primary care across Liverpool in the North West of England and explored behaviours influencing opioid treatment with Health Care Professional (HCP) and CNCP patients. A mixed-methods approach was used in the three studies of this research programme. Study 1 was a quantitative analysis of N=93,236 opioid prescriptions issued to N=30,474 patients for CNCP across Liverpool Clinical Commissioning group (LCCG) during 2016-2018. Study 2 was a thematic analysis of semi-structured interviews with HCPs (n=16) and CNCP patients (n=13) to better understand the behaviours associated with treating, and being treated with, opioids for CNCP pain. Study 3 developed a set of recommendations for an opioid weaning intervention, based on the findings of studies 1 and 2, using the 3-stage framework of the Behaviour Change Wheel (BCW). This systematically and theoretically informed the intervention content to facilitate opioid weaning. Feasibility and acceptability consultations with HCPs(n=8) and CNCP participants(n=3) were subsequently conducted online to establish consensus and refinement of the proposed recommendations. The findings from study 1 revealed that 3.5% (n=1,060) of patients in Liverpool are prescribed opioids above 120mg MED/day. Most patients are female (66%), with an average age of 58 years, located in North Liverpool, and likely to receive n=3 opioids attributing to their total daily dose. This provides some indication of where and who an intervention of this kind might target in Liverpool. The findings of study 2 with contributions from the literature helped identify a range of behaviours (n=34) associated with opioid weaning. Guided by the BCW in study 3, these behaviours were prioritised and 3 were selected to target the change needed to reduce or discontinue opioids. These include 1) improving adherence to opioid weaning, 2) reducing patients fear and anxiety and 3) improving information and support for opioid weaning. Feedback from HCPs and CNCP participants revealed the need to also consider addressing issues of initially engaging patients and support available for HCPs delivering the intervention and carers of patients weaning. To trigger the change needed, 6 intervention functions and 24 unique BCTs delivered via a mixture of face-to-face, online, and individual and group methods are recommended. A small but significant proportion of CNCP patients are in receipt of opioids at doses eliciting little pain relief whilst increasing risk of harm. Given the economic and social impact of CNCP, reducing this risk of harm and optimising pain management is a public health priority. This study has proposed content for a behavioural change intervention that will target opioid weaning in a primary care setting