Highlights
- Patient-centered opioid tapering with close monitoring enables successful dose reduction or improved pain control in approximately half of chronic pain patients on long-term opioids.
- Adding cognitive behavioral therapy (CBT) or chronic pain self-management programs (CPSMP) to tapering did not significantly increase taper success compared to taper alone at 12 months.
- Inclusion of CBT may reduce adverse events, including opioid withdrawal symptoms, enhancing patient safety during tapering.
- Digital interventions such as the Summit program demonstrate feasibility and patient acceptability but face challenges in recruitment and engagement, highlighting the need for further research.
Background
Chronic pain affects millions globally and long-term prescription opioid therapy (LTOT) is frequently used despite limited efficacy for persistent non-cancer pain and significant risks including dependency and overdose. Clinical guidelines emphasize individualized, patient-centered opioid tapering to mitigate harms. However, outpatient settings face challenges implementing effective tapering strategies that balance dose reduction with pain control and patient safety. Behavioral therapies such as cognitive behavioral therapy for chronic pain (pain-CBT) and self-management programs are proposed adjuncts to support tapering, yet robust comparative effectiveness evidence has been lacking. Recent research addresses these gaps to inform best practices for opioid de-escalation.
Key Content
Evidence from the EMPOWER Randomized Clinical Trial (2026)
The pivotal EMPOWER trial conducted across 11 U.S. sites enrolled 562 adults experiencing chronic pain (≥6 months) on moderate or higher daily opioid doses (MEDD ≥10) without severe opioid use disorder. Participants were randomized to one of three arms:
- Taper only: Patient-centered opioid tapering with close clinical monitoring and electronic support.
- Taper plus pain-CBT: Same tapering protocol augmented by structured cognitive behavioral therapy focused on chronic pain.
- Taper plus chronic pain self-management program (CPSMP): Tapering plus a peer-led group program targeting skills for pain self-management.
The primary outcome, taper success, was defined as either a ≥50% MEDD reduction without increased pain or stable opioids with a decrease in pain intensity at 12 months. Results showed similar taper success rates across groups: 50.9% (taper only), 48.6% (taper plus pain-CBT), and 44.5% (taper plus CPSMP). Statistical analyses demonstrated no significant differences between adjunct behavioral therapies and taper only (pain-CBT vs. taper only difference: -2.4 percentage points [95% CI, -11.9 to 7.2]; CPSMP vs. taper only: -5.2 percentage points [95% CI, -15.3 to 4.8]).
Importantly, adverse event rates including opioid withdrawal symptoms were highest in the taper only group (66%), moderately reduced with pain-CBT (54%), and slightly improved with CPSMP (64%), suggesting behavioral therapies may ameliorate taper-related adverse effects despite no improvement in taper success rates.
Several study limitations include COVID-19 pandemic-related enrollment impacts leading to smaller and imbalanced groups, suboptimal adherence to behavioral interventions, and some losses to follow-up—all potentially attenuating observed efficacy of adjunct therapies.
Complementary Evidence from Digital Health Interventions
Parallel research developed and piloted digital behavioral support tools to aid opioid tapering. The Summit program is a web-based, theory-informed digital platform incorporating education, motivational content, self-management skills, and peer support elements delivered asynchronously to patients undergoing opioid tapering.
A 2026 pilot feasibility RCT in Veterans (N=44) demonstrated high retention and acceptability but low utilization of the digital content. Approximately one-third of participants reported opioid reduction during the trial, indicating potential benefit. Qualitative feedback underlined how structured monitoring facilitated patient engagement with pain and opioid use planning. However, recruitment challenges and low program use signal a need to refine strategies before larger definitive trials.
Earlier protocol publications (2022) focused on Summit’s development highlight the importance of stakeholder engagement and usability testing in designing supportive digital environments for opioid tapering, laying groundwork for scalable adjunctive tools.
Expert Commentary
The EMPOWER trial provides landmark comparative effectiveness data clarifying that while patient-centered opioid tapering with electronic supports is effective and achievable for many patients, the addition of behavioral therapies such as pain-CBT or CPSMP does not improve the primary outcome of taper success at 12 months. This insight challenges assumptions about universally additive benefits of structured behavioral interventions during tapering, emphasizing the potency of a well-monitored tapering approach itself.
The reduction in adverse events, particularly withdrawal symptoms, with pain-CBT underlines its utility in improving patient safety and experience. This suggests integration of CBT could be prioritized for patients at higher risk of withdrawal or adverse effects rather than applied universally.
The COVID-19 pandemic introduced recruitment and adherence challenges which may have diminished the measurable impact of behavioral treatments. Further research with optimized engagement strategies is justified to delineate behavioral therapy roles.
Digital interventions like Summit offer promising frameworks for scalable, patient-centered support but require enhancements in accessibility and adherence. Combining digital tools with clinical monitoring could complement traditional models, especially in resource-limited or pandemic-affected settings.
Mechanistically, behavioral therapies may mitigate opioid withdrawal and pain catastrophizing via cognitive restructuring and skill acquisition, enhancing coping with reduced opioid doses. The lack of additive impact on dose reduction success might reflect the overriding importance of personalized taper pacing and clinical engagement provided in all study arms.
Conclusion
Patient-centered opioid tapering with close clinical monitoring supported by electronic feedback systems enables successful dose reduction or pain improvement in about half of patients with chronic pain on long-term opioids. Adding cognitive behavioral therapy or chronic pain self-management programs does not increase taper success rates at one year but may reduce adverse symptoms, particularly opioid withdrawal.
Digital health applications, such as the Summit program, are feasible adjuncts with acceptable patient engagement, though optimization for greater adoption and impact is needed.
Future research should explore tailored integration of behavioral therapies targeting patients most likely to benefit, and refined digital supports combined with clinical oversight may enhance opioid tapering success and safety. Addressing barriers introduced by healthcare disruptions, such as pandemics, remains critical for robust evaluation.
References
- Darnall BD et al. Patient-Centered Prescription Opioid Tapering Methods: A Randomized Clinical Trial. Ann Intern Med. 2026 Jul 7; PMID: 42407075. doi: 10.7326/ANNALS-25-04784.
- Keosaian J et al. Summit program to taper long-term opioid therapy in Veterans: A mixed-methods feasibility study. J Pain. 2026 Apr;41:106207. PMID: 41666948. doi: 10.1016/j.jpain.2026.106207.
- Keosaian J et al. Opioid tapering support using a web-based app: Development and protocol for a pilot randomized controlled trial. Contemp Clin Trials. 2022 Aug;119:106857. PMID: 35863697. doi: 10.1016/j.cct.2022.106857.
- Darnall BD et al. Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol. Pain Med. 2020 Aug;21(8):1523-1531. PMID: 31876947. doi: 10.1093/pm/pnz285.
