Worsening, Fluctuating Pain Increases Return to Prescription Opioids after Buprenorphine-Naloxone Taper, but Additional Drug Counseling Might Help

Patients with opioid use disorder (OUD) who have chronic pain and receive addiction treatment are at the greatest risk of return to opioid use. To determine whether pain trajectory (i.e., worsening) and volatility (i.e., fluctuating) predict opioid use after buprenorphine-naloxone (BUP-NLX) taper, this secondary analysis examined 125 patients with OUD and chronic pain who received a BUP-NLX taper in phase 2 of the multisite Prescription Opioid Addiction Treatment Study (POATS). POATS recruited from community clinics affiliated with a national clinical trials network in 10 US cities.

• Opioid use increased during the 4-week taper period, from 22% of urine screens positive in week 13 to 31% in week 16.
• While baseline pain severity was not predictive, increasing pain over time (time slope odds ratio [OR], 2.38), as well as greater pain volatility (OR, 2.43) during BUP-NLX treatment predicted any opioid use during the taper phase. Increasing pain over time (incidence rate ratio [IRR], 1.4), as well as greater pain volatility (IRR, 1.66) during BUP-NLX treatment similarly predicted more days per week of opioid use.
• Additional drug counseling lowered opioid use (OR, 0.17) in the subgroup with chronic pain, even though it did not demonstrate effects in the overall study.

Comments: This study suggests that the dynamics of chronic pain (i.e., worsening or fluctuating) are better predictors of return to opioid use than its static severity. This finding makes intuitive sense as an exacerbating or waxing-waning pattern makes it difficult for patients to acclimate to a stable level of pain. An unexpected finding was the benefit of additional drug counseling in the subgroup with chronic pain, which perhaps teaches coping skills to prevent it from triggering recurrent use. This finding merits replication.

Peter D. Friedmann, MD

Reference: Worley MJ, Heinzerling KG, Shoptaw S, Ling W. Volatility and change in chronic pain severity predict outcomes of treatment for prescription opioid addiction. Addiction. 2017;112(7):1202–1209.