discontinuation vs continuation of long-term opioid therapy in suboptimal and optimal responders with chronic pain

Conditions: Opioid-Related Disorders; Opiate Addiction; Narcotic Abuse; Drug Abuse

Summary: the purpose of this study is to evaluate the effect on pain intensity (pi) of structured discontinuation of long-term opioid analgesic therapy compared to continuation of opioid therapy in suboptimal and optimal responders to high-dose, long-term opioid analgesic therapy for chronic low back pain (clbp).

this was a multicenter, randomized, double-blind, placebo-controlled study which consisted of a common screening visit for all subjects, then different schedules for optimal and suboptimal responders, followed by a common schedule for the blinded structured opioid discontinuation period (bsodp) and follow-up period. the original protocol (10 jan 2016) was amended twice: amendment 1 (07 jul 2016) and amendment 2 (08 feb 2017). screening of subjects only started after amendment 1 approval. approximately half the subjects were screened under amendment 1 and half under amendment 2. the original statistical analysis plan (sap) was amended twice as well based on the protocol amendments. the current sap is version 1.3, dated 11 april 2018, which added a section to list the analyses that were not being completed as a result of the premature termination of this study. the duration of the entire study for each subject was approximately 33 to 37 weeks. for suboptimal responders: the study duration included screening period of up to 3 weeks, run-in period of 1 week, baseline period of 1 week, blinded structured opioid discontinuation period of 24 weeks, and follow-up period of 4 weeks. for optimal responders: the study duration included screening period of up to 3 weeks, observation period of 1 week, taper period up to 2 weeks, open label titration period of 3 weeks, blinded structured opioid discontinuation period of 24 weeks, and follow-up period of 4 weeks. the primary endpoint was the change in the mean average pi score on the 0-10 numerical ratings scale (nrs) from baseline to the 1 week period before the week 12 visit. data were summarized using descriptive statistics (number of observations \[n\], mean, standard deviation, median, first and third quartiles, minimum, and maximum for continuous variables; and frequency and percentage for categorical variables). due to the inability to recruit a sufficient number of subjects over an acceptable period of time, the study was terminated prematurely and efficacy analyses were reduced and only a brief summary of the statistical analyses of the primary endpoint in each group (suboptimal responders and optimal responders) were performed.

Eligibility criteria:
inclusion criteria: 1. be male or non-pregnant, non-lactating female aged 18 to 75 years, inclusive. 2. have a clinical diagnosis of non-radicular clbp (pain that occurs in an area with boundaries between the lowest rib and the crease of the buttocks) of class 1 or proximal radicular (above the knee) pain of class 2 based on the quebec task force classification for spinal disorders (subjects with previous surgery or chronic pain syndrome, i.e., classes 9.2 or 10, will be allowed if their pain does not radiate or radiates only proximally) for a minimum of 12 months and 1. for the suboptimal responder group, pain must have been present for at least several hours a day and have an average pi score of 6-9 on an 11-point nrs within the past 24 hours of screening. 2. for the optimal responder group, subjects must have an average pi score of 1-4 on an 11-point nrs within the past 24 hours of screening. 3. have been taking er/la opioids or immediate release opioids (at least 4 times at day) for at least 12 months. 4. have been taking one of the 3 index er opioid drugs around-the-clock at a twice-a-day frequency for at least 3 consecutive months at a total daily dose within the range shown below. daily dose range 1. morphine sulfate extended-release: 120-540mg 2. oxycodone extended-release: 80-360mg 3. oxymorphone extended-release: 40-180mg 5. be considered, in the opinion of the investigator, to be in generally good health other than clbp at screening based upon the results of a medical history, physical examination, 12-lead ecg, and laboratory profile. 6. speak, read, write, and understand english (to reduce heterogeneity of data), understand the consent form, and be able to effectively communicate with the study staff. 7. have access to the internet (to access the patient support program). 8. voluntarily provide written informed consent. 9. be willing and able to complete study procedures. exclusion criteria: 1. have any clinically significant condition that would, in the opinion of the investigator, preclude study participation or interfere with the assessment of pain and other symptoms of clbp or increase the risk of opioid-related aes. 2. have a primary diagnosis of fibromyalgia, complex regional pain syndrome, neurogenic claudication due to spinal stenosis, spinal cord compression, acute nerve root compression, severe or progressive lower extremity weakness or numbness, bowel or bladder dysfunction as a result of cauda equina compression, diabetic amyotrophy, meningitis, diskitis, back pain because of secondary infection or tumor, or pain caused by a confirmed or suspected neoplasm. 3. have undergone a surgical procedure for back pain within 6 months prior to the screening visit. 4. have had a nerve or plexus block, including epidural steroid injections or facet blocks, within 1 month prior to the screening visit or botulinum toxin injection in the lower back region within 3 months prior to screening. 5. have a history of confirmed malignancy within past 2 years, with exception of basal cell or squamous cell carcinoma of the skin that has been successfully treated. 6. have uncontrolled blood pressure, i.e., subject has a sitting systolic blood pressure \>180 mm hg or \ 110 mmhg or \<40 mm hg at screening. 7. have a body mass index (bmi) \>45 kg/m2. anyone with a bmi \>40 but \<45 will complete a screening tool (stopbang questionnaire) to rule out high risk of obstructive sleep apnea. 8. have clinically significant depression based on a score of ≥20 on the patient health questionnaire (phq-8) 9. have suicidal ideation associated with actual intent and a method or plan in the past year: "yes" answers on items 4 or 5 of the columbia-suicide severity rating scale (c-ssrs). 10. have a previous history of suicidal behaviors in the past 5 years: "yes" answer (for events that occurred in the past 5 years) to any of the suicidal behavior items of the c-ssrs. 11. have any lifetime history of serious or recurrent suicidal behavior. (non-suicidal self-injurious behavior is not a trigger for a risk assessment unless in the investigator's judgment it is indicated.) 12. have clinically significant abnormality in clinical chemistry, hematology or urinalysis, including serum glutamic-oxaloacetic transaminase/aspartate aminotransferase or serum glutamic pyruvic transaminase/alanine aminotransferase ≥3 times the upper limit of the reference range or a serum creatinine \>2 mg/dl at screening. 13. have severe enough psychiatric or substance abuse disorder to compromise the subject's safety or scientific integrity of the study. 14. have on-going litigation associated with back pain or pending applications for workers compensation or disability issues or subjects who plan on filing litigation or claims within the next 12 months; subjects with settled past litigations will be allowed as will subjects who have been on workers compensation or disability claims for at least 3 months. 15. have used a monoamine oxidase inhibitor within 14 days prior to the start of study medication. 16. are taking agonist-antagonists (pentazocine, butorphanol or nalbuphine), buprenorphine, methadone, barbiturates, or more than one type of benzodiazepine within 1 month prior to screening. 17. have a positive urine drug test (udt) for illicit drugs (including marijuana), non-prescribed controlled substances (opioid or non-opioid), or alcohol at screening. 18. have taken any investigational drug within 30 days prior to the screening visit or are currently enrolled in another investigational drug study.