Психотерапия не повышает эффективность снижения доз опиоидов, но облегчает синдром отмены

Adding cognitive behavioral therapy (CBT) or a chronic pain self-management program to a patient-centered prescription opioid taper does not improve taper success at 12 months, although CBT may reduce opioid withdrawal symptoms and other adverse events, according to study findings published in Annals of Internal Medicine. Evidence comparing approaches to long-term prescription opioid tapering remains limited, despite recommendations that tapering be both individualized and patient centered. Behavioral support has been proposed as a way to improve outcomes during opioid dose reduction, but comparative evidence regarding its added benefit has been lacking. Researchers conducted the Effective Management of Pain and Opioid-Free Ways to Enhance Relief (EMPOWER; ClinicalTrials.gov Identifier: NCT03445988 ) study, a 3-group, randomized clinical trial conducted at 11 US sites, to compare patient-centered opioid tapering alone with tapering plus 1 of 2 behavioral pain interventions. Eligible participants were adults with pain lasting at least 6 months who had received a morphine equivalent daily dose (MEDD) of at least 10 for 3 months or longer and did not have moderate or severe opioid use disorder. All participants received an individualized tapering plan developed with their prescribing clinician. Rather than requiring opioid discontinuation, the intervention aimed to identify each patient’s lowest comfortable dose during 12 months, with patients permitted to adjust the tapering pace or pause dose reductions. Follow-up visits occurred approximately every 3 to 4 weeks, and electronic symptom monitoring was used to identify potential taper-related problems. Future randomized tapering study designs may include equipoise in behavioral intervention assignment, prespecified examination for incidence rate and type of opioid withdrawal symptoms and other adverse events, and objective assessments and electronic medical record data. Researchers assigned 562 participants across 3 treatment groups: taper only (n=191), taper plus CBT for chronic pain (pain-CBT; n=203), and taper plus a chronic pain self-management program (CPSMP; n=168). Pain-CBT consisted of 8 weekly group sessions focused on pain education and management skills, while CPSMP consisted of 6 weekly peer-led sessions addressing pain education, self-management strategies, and action planning. The primary outcome was taper success at 12 months, defined as either a reduction in MEDD of at least 50% without increased pain intensity or no increase in MEDD accompanied by clinically meaningful improvement in pain. Mean participant age was 58±13 years; 52.7% were women. Approximately 77% of participants were White, and 99% were considered unlikely to have alcohol or drug dependence. Mean pain duration was 16.4±11.3 years, and participants had used prescription opioids for a mean of 12.4±9.8 years. Mean baseline pain intensity was 6.2±1.9 on a 10-point scale, while mean and median MEDD were 125.1 and 60, respectively. Some baseline imbalances were observed among treatment groups, including differences in study site, ethnicity, household income, employment status, and number of pain conditions. At 12 months, taper success was achieved by 50.9% (95% CI, 42.9%-58.9%) of participants in the taper-only group, 48.6% (95% CI, 41.0%-56.2%) of those receiving taper plus pain-CBT, and 44.5% (95% CI, 36.0%-53.3%) of those receiving taper plus CPSMP. Compared with taper only, the adjusted risk difference was −2.4 percentage points (95% CI, −11.9 to 7.2) with pain-CBT and −5.2 percentage points (95% CI, −15.3 to 4.8) with CPSMP, indicating no improvement in taper success from either behavioral intervention. Results were consistent in the per-protocol analysis. Study-related adverse events occurred among 66% of participants receiving taper only, compared with 54% receiving taper plus pain-CBT and 64% receiving taper plus CPSMP. Opioid withdrawal symptoms were reported among 61%, 49%, and 60% of participants, respectively. Post hoc findings showed fewer withdrawal-related events among participants receiving taper with pain-CBT than among those receiving taper only, with a 54% lower incidence rate of opioid withdrawal symptoms (IRR, 0.46; 95% CI, 0.33-0.64). Taper with pain- CBT was also associated with a 52% lower incidence rate of overall study-related adverse events (IRR, 0.48; 95% CI, 0.35-0.66). Researchers reported no study-related serious adverse events, including overdose, hospitalization, or death. Study limitations include the reduced sample size and treatment-group imbalances related to the COVID-19 pandemic, low participation in the assigned behavioral interventions, and potential bias from self-reported opioid and pain data. Researchers also noted that adverse event and withdrawal symptom comparisons were not prespecified and that losses to follow-up may have affected estimates of treatment effectiveness. “Future randomized tapering study designs may include equipoise in behavioral intervention assignment, prespecified examination for incidence rate and type of opioid withdrawal symptoms and other adverse events, and objective assessments and electronic medical record data,” the study authors concluded. This article originally appeared on Rheumatology Advisor References: Darnall BD, Perez L, Kao MC, et al. Patient-centered prescription opioid tapering methods: a randomized clinical trial. Ann Intern Med. Published online July 7, 2026. doi:10.7326/ANNALS-25-04784