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Patients with chronic pain who are tapering prescription opioids report a need for greater support for coping with symptoms of pain and withdrawal. Mobile health (mHealth) technologies (SMS text messaging– or app-based) have the potential to provide patients with educational, emotional, and motivational support for opioid tapering beyond what is offered by their health care provider. However, it is not known whether patients with chronic pain who are tapering opioids would be willing or able to engage with technology-based support.
This study aims to examine patients’ use of mobile technologies in health care, interest in using mHealth support, preferences for the form and content of mHealth support, and potential barriers to and facilitators of engagement with mHealth support for opioid tapering.
A total of 21 patients (11 women and 10 men; age range 29-83 years) with chronic noncancer pain on long-term opioid therapy who had recently initiated a voluntary opioid taper were recruited from primary and tertiary care clinics in metropolitan and regional Australia for a larger study of patients’ experiences of opioid tapering. Participants had been taking prescription opioids for a mean duration of 13 (SD 9.6; range 0.25-30) years at the time of the study. Survey items characterized participants’ typical mobile phone use and level of interest in mobile technology–based support for opioid tapering. Semistructured interviews further explored patients’ use of mobile technologies and their interest in, preferences for, and perspectives on potential barriers to and facilitators of engagement with mHealth support for opioid tapering. Two researchers collaborated to conduct a thematic analysis of the interview data.
All participants reported owning and using a mobile phone, and most (17/21, 81%) participants reported using mobile apps. The majority of participants expressed interest in SMS text messaging–based (17/21, 81%) and app-based (15/21, 71%) support for opioid tapering. Participants expected that messages delivering both informational and socioemotional support would be helpful. Participants expected that access to technology, mobile reception, internet connectivity, vision impairment, and low self-efficacy for using apps may be barriers to user engagement. Patients expected that continuity of care from their health care provider, flexible message
The results of this study indicate that patients with chronic noncancer pain may be willing to engage with SMS text messaging–based and app-based mHealth interventions to support opioid tapering. However, the feasibility and acceptability of these interventions may depend on how patients’ preferences for functionality, content, and design are addressed.
Chronic pain is one of the leading causes of disability worldwide, affecting approximately 1 in 5 adults [
Current guidelines recommend that patients on long-term opioid therapy for CNCP should be gradually tapered off these medications under the guidance of a health care provider [
Emerging data suggest that when patients volunteer to taper, a patient-centered, multimodal approach involving pain education, nonpharmacological pain self-management strategies, routine follow-up with a trusted health care provider, and support for coping with pain and withdrawal symptoms may improve outcomes [
Mobile health (mHealth) interventions may be an effective means of overcoming many of these barriers to opioid tapering in patients with CNCP [
The potential benefit of SMS text messaging–based interventions to support opioid tapering in patients with CNCP is supported by studies investigating the use of telephone-delivered messages to support chronic pain management, on the one hand, and opioid tapering, on the other. First, a 2010 study investigated the effect of delivering automated telephone voice messages to patients to remind them to use pain self-management skills after they completed an 11-week group pain management program. The researchers found that those who received the messages used fewer opioid medications 8 months after the pain management program compared with participants who did not receive digital aftercare [
Although these studies point to the potential of mHealth interventions to support prescription opioid tapering in individuals with chronic pain, there is currently no direct evidence that patients with chronic pain would be willing to engage with mHealth interventions as a means of support for opioid tapering and, if so, whether or not they would be able to engage with these technologies. This study aims to explore patients’ access to and use of mobile technology, interest in mHealth support for opioid tapering, preferences for the form and content of mHealth support, and potential barriers to and facilitators of engagement with mHealth support for opioid tapering. Using a combination of survey and interview methods to achieve these objectives, we also aim to elicit consumer perspectives to inform the design, content, and functionality of an mHealth intervention.
Participants were recruited from a private primary care practice in regional New South Wales and a public tertiary pain clinic in a metropolitan area in Australia between September 2019 and March 2020. The Human Research Ethics Committee of the Northern Sydney Local Health District approved the study (study 2019/STE00599).
Eligible participants were those who were aged >18 years, were living with CNCP (pain persisting for ≥6 months), had been taking opioid medications for chronic pain for >3 months, and voluntarily commenced or planned to commence opioid tapering. Exclusion criteria included a history of opioid use disorder, major psychiatric conditions, insufficient English proficiency, or inability to provide informed consent. Patients with comorbid opioid use disorder were excluded from the study because the challenges faced by these patients when tapering are potentially more complex, requiring greater medical management, and the needs of this group are not necessarily shared by most patients tapering opioids for chronic pain [
Data for this study were collected as part of a larger investigation into the experience of tapering in patients with CNCP. Patients who met the inclusion criteria were asked if they would be interested in hearing about the study. A researcher (AGM) contacted interested patients to obtain their informed consent to participate. Participants completed a very brief survey before or within the first few weeks of voluntarily tapering prescription opioids. Participants were later (during the first three months of their taper) interviewed (by AGM) and asked to elaborate upon their survey responses. A total of 2 independent researchers (MRM and CEAJ) analyzed the survey and interview data.
The survey was designed to gather descriptive data on the sample of participants’ use of mobile phone technology (specifically SMS text messaging, apps, and health apps) and level of interest in engaging with mHealth support for opioid tapering (
Semistructured interview questions were designed to further explore patterns of mobile phone and app use among participants in this cohort (eg, “How often do you use your phone?” and “At what times of day do you typically use your phone?”), identify reasons why participants expressed an interest or lack of interest in mHealth support for opioid tapering (eg, “You’ve said you would prefer SMS-based support over app-based support. Why is that?”), elicit participants’ preferences for the form and content of an mHealth intervention (“Do you have any thoughts on what kind of information would be helpful?” and “What advice would be helpful for someone who was about to taper their opioid medication?”), and explore potential barriers to and facilitators of engagement with mHealth support for opioid tapering (eg, “Why do you feel it would not be helpful for you?” and “Is there a time of day you might be more or less likely to look at it?”).
An interview guide was prepared as a prompt for interviewers to focus their discussion on issues pertinent to the aims of the study (
A total of 21 participants were recruited for this study. Participants were recruited until sample heterogeneity was achieved in terms of age, tapering experience, gender, education level, employment status, health care setting, pain duration, and opioid use duration. One participant withdrew from the study after completing the survey but before being interviewed for this study (discontinued tapering). Overall, 62% (13/21) of participants were recruited from a tertiary pain clinic, and 38% (8/21) of participants were recruited from primary care.
Most participants (17/21, 81%) reported prior experience with opioid tapering. Tapering experience was variable, including tapering from a very high dose to a moderate dose, with subsequent tapering to further reduce the dose. Others had successfully reduced or discontinued opioid medications in the past but had resumed opioid use after an accident or injury and were motivated to taper again. Participants were not recruited for this study based on their mHealth use or level of comfort with digital technology.
Participant characteristics (N=21).
Characteristics | Values | ||
Age (years), mean (SD; range) | 55 (12.26; 29-83) | ||
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Female | 11 (52) | |
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Male | 10 (48) | |
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Tertiary pain clinic | 13 (62) | |
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Primary care | 8 (38) | |
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High school graduate | 3 (14) | |
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Vocational training | 6 (29) | |
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Bachelor’s degree | 7 (33) | |
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Postgraduate degree | 2 (10) | |
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Data missing or not reported | 3 (14) | |
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Single | 2 (10) | |
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Married | 10 (48) | |
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In a relationship | 3 (14) | |
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Widowed | 2 (10) | |
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Data missing or not reported | 4 (19) | |
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Employed | 4 (19) | |
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Unemployed or not working | 16 (78) | |
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Data missing or not reported | 1 (5) | |
Pain duration (years), mean (SD; range) | 13 (9.6; 0.25-30) | ||
Duration of opioid treatment (years), mean (SD; range) | 9.3, (7.5; 0.25-30) | ||
Oral morphine equivalent daily dose (mg), mean (SD; range) | 150 (229.29; 20-1080) |
Interview data were audio recorded and then transcribed verbatim into NVivo 12 (QSR International), a software platform for the qualitative coding and analysis of data [
All participants (21/21, 100%) reported using a mobile phone. Most participants (17/21, 81%) reported using mobile apps, including health and wellness apps (10/21, 47%). Overall, 81% (17/21) of participants reported being
Survey results.
Survey item and response option | Frequency, n (%) | ||
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Yes | 21 (100) | |
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No | 0 (0) | |
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Not interested at all | 0 (0) | |
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Not interested | 3 (14) | |
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Neither interested nor disinterested | 1 (5) | |
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Interested | 16 (76) | |
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Very interested | 1 (5) | |
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Yes | 17 (81) | |
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No | 4 (19) | |
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Yes | 10 (48) | |
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No | 9 (43) | |
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Not interested at all | 2 (9) | |
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Not interested | 2 (9) | |
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Neither interested nor disinterested | 0 (0) | |
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Interested | 13 (62) | |
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Very interested | 2 (9) | |
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Missing responses | 2 (9) |
During interviews, participants revealed that they most commonly used their mobile phones to communicate with others and did so via phone calls, SMS text messaging, and apps (eg, WhatsApp and Facebook Messenger). Participants reported using apps, including internet browsers, calendars, web-based booking platforms, games, banking, news, and social media. One participant reported using apps to record and listen to sessions with a psychologist for pain management support.
The frequency of phone use varied. Participants indicated that they had access to their phones all the time (“They’re kind of attached to you,” P18, male, 41 years, pain clinic, regional area), even if they did not always use them (“It’s just for emergencies,” P13, male, 51 years, pain clinic, metropolitan area)
I struggle to get out of bed in the mornings because I don’t sleep well and that’s generally the point of time where the medication has worn off from the night before.
The proposed delivery of support via SMS text messaging or an app was perceived generally as positive:
I think just getting the support no matter what form it is in is helpful.
Some participants reported that electronic delivery of motivation and encouragement would be welcome:
I think any form of motivation is helpful.
A primary benefit of an mHealth intervention reported by participants was increased access to support for opioid tapering during periods when other services were not available (ie, out of office hours):
That’s where messages are going to work well...these [worries] can [come] at two in the morning and you need a response...It can be an automated thing.
One participant reported that an mHealth intervention would be beneficial as she had “nobody checking in to see how I am” over the Christmas period:
I think the mobile system would be good for that because it feels like you have some way of reaching someone or some way of someone reaching you to check in.
Although participants were, in general, interested in using SMS text messaging–based or app-based support for opioid tapering, they also expressed a strong preference for clinician-delivered support either face-to-face or over the phone:
I like being able to I guess just talk...I tend to kind of ignore my texts sometimes if I’m busy.
No I think it’s better to talk to somebody...No, I’d sooner talk over the phone.
I think the phone call thing is better than any social media, better than anything you just type in or anything because it’s human.
There were concerns about how this would be interpreted if it was clear that the support was computer delivered:
If it’s just a text message, I’m not dumb, I know it’s just a computer sending it. If it gets sent out the same time every day, it’s a computer sending it.
Participants reported some skepticism that automated messages would feel genuine:
If I think I’m getting just some random “great you’re doing well” and I know it’s been automatically generated, I probably wouldn’t be that tickled by it.
Participants who did not express an interest in an mHealth intervention to support opioid tapering reasoned either that they had a strong desire for face-to-face support (“I think personally you need to be human to human,” P21, male, 53, primary care, regional area) or a preference for alternative sources of information and support:
I would probably prefer just reading information or just talking to someone before using an app. If there was a web page, I’d probably be likely to use the web page more.
However, one participant reported a preference for SMS text messaging rather than a phone call or face-to-face check in:
The text messaging I think would be really good because the thing that probably scares me most is to speak to someone about it.
In line with the preference for face-to-face and nonautomated services outlined earlier, several participants recommended that an option for personal follow-up be built into the service:
I think the mobile system would be good for that because it feels like you have some way of reaching someone or some way of someone reaching you to check in.
Most participants did not express a strong preference for either SMS text messaging–based or app-based support. Participants who expressed a preference for SMS text messaging–based support indicated a higher level of familiarity with text messaging:
I can use [SMS] easier...because I don’t use my phone much for that sort of thing [apps].
Participants who expressed a preference for app-based support reasoned that apps may provide access to more content:
I’m guessing inside that app there would be probably more information than in the texts.
One participant stated that, although they were willing to read texts, they did not like to respond to them:
I just hate texting.
Participants provided recommendations for content that they believed would be helpful in an mHealth intervention. Specifically, they expressed interest in receiving information about pain management during flare-ups and about withdrawal from opioid medications (informational support and reassurance) and messages of encouragement, motivation, and validation (socioemotional support and reassurance).
Several participants expressed a desire for information related to pain self-management strategies:
I think it would be really useful to have maybe different things on there like techniques to help. “If you’ve got really bad pain, why don’t you try this?”
I think it would be nice to have like an app or texting or whatever that did embody like the mindfulness and the meditation and the feedback, so it’s all in one place.
It’s about thought and relaxation...thought management.
One participant recommended tailoring the information to reflect the user’s stage of tapering to reassure them that what they were experiencing was normal:
Maybe “You’re on week 4 of your taper and you’re on this dose. Be mindful that you may experience this, this, and this.” So, give them a bit of warning. And “good ways to deal with those things are...” Then people know that they’re normal. Once people go “oh okay this is normal,” you take the fear out of it.
Another participant agreed that knowing what to expect, particularly with regard to withdrawal symptoms, would be empowering:
I didn’t know what to expect. I thought it might just get worse and worse and worse for weeks. If I just had a time frame and it might be different...If I had been warned that you could get constipation and you’ll need to take precautions.
A number of participants commented more generally on the importance of social support when tapering, either from friends and family, a group within a treatment program, or clinicians. One participant recommended integrating electronic social support for patients who were tapering their opioid medication:
If you can push for a forum or something, I think that would be awesome.
Participants’ views regarding the acceptability of mHealth interventions for opioid tapering were influenced by factors such as the frequency of the messages and pattern of delivery. One participant preferred receiving messages at night (“Probably early evening just as you’re winding down, to help me to wind down properly,” P04, male, 57 years, pain clinic, metropolitan area), whereas another was concerned about receiving too frequent or too repetitive messages. Their suggestion to counter this was for the digital service to be responsive to the needs of the user:
So maybe there is a text that’s in response to a word we send out. Like we need some affirmation...It could be geared to that more.
Several participants described perceived barriers toward phone-based digital interventions including limited phone reception or access to internet:
I don’t have Wi-Fi. I can’t afford it.
I don’t think my old phone will support it.
Some participants spoke about vision impairment:
I use glasses and my phone is a very cheap phone. If it’s in the middle of the day I can’t read them.
For the older ones they can’t see stuff on their phone properly.
Some participants reported that low confidence in using mobile devices and apps may be an obstacle to engagement with app-based interventions:
No, I wouldn’t know how [to use apps]...I’m not tech savvy.
Relatedly, some participants suggested that ease of use and simplicity of content would facilitate engagement:
If it’s not too time consuming and it’s not complicated...your average person isn’t [so tech savvy] so it can’t be complicated.
At the same time, one participant suggested that their confidence in using mHealth interventions could be improved if provided with technical support (P20, female, 63 years, pain clinic, metropolitan area).
Participants in the study had varying levels of familiarity and experience with pain self-management strategies, and one participant suggested that it may be difficult to engage with digitally delivered pain self-management advice if one is not already experienced in using them:
You don’t go driving on your own for the first time. You have to get the license. You need your lessons first...I would hate to have to do this [pain self-management] and not know how.
Participants predicted that their level of interest and engagement with mHealth support may fluctuate over the course of their taper depending on their mood, pain, and state of mind:
Whether I looked at it or not would depend I guess on my mood—how I’m feeling, where I am.
At the time you receive it you mightn’t be that open to it but in a few hours’ time when you’re starting to struggle a bit or the next day it may be something you open up again and read through.
Whether the content was automated, personalized, and integrated with face-to-face treatment was identified as a potential barrier to engagement. Participants were concerned that receiving impersonal (automated and standardized) messages may not have the same impact as receiving individualized messages from a person in real time:
The text message, in reality that’s still a computer sending it, there’s not someone at the end of it that’s sending it. I don’t know whether it would just get irritating after a while because I know nothing is going to come of it, like there is no one at the other end. Or whether it would just jolt me out of feeling sorry for myself or something. I guess it depends how it’s worded.
The results revealed that all participants owned and used mobile phones. Most participants reported using smartphone apps. The majority of participants expressed interest in SMS text messaging–based and app-based support for tapering prescription opioids. Mostly, participants held no strong preference for either SMS text messaging or app support. Variables potentially influencing acceptability included message simplicity, messaging frequency, time of delivery, responsivity to user needs, individual stage of tapering, and mental state There was a strong preference for clinician-delivered, individualized, real-time support over automated and standardized mHealth support. At the same time, however, a perceived benefit of mHealth was increased accessibility of opioid tapering support. Content recommendations included pain self-management and opioid withdrawal information as well as encouragement, motivation, and validation. Perceived barriers included limited phone or internet reception and low confidence in using mobile devices and apps. These results suggest that SMS text messaging–delivered or app-delivered support may be acceptable, feasible, and even helpful to individuals living with CNCP who are tapering opioids. However, participants identified a number of barriers to engagement that may be critical to address in the development of such an mHealth intervention.
mHealth interventions are typically delivered via an app or SMS text messaging. Participants identified barriers such as access to technology, mobile reception, internet connectivity, vision impairment, and low confidence in using apps. Most of these obstacles can be overcome by using an SMS text messaging–based intervention rather than an app-based intervention. SMS text messaging–based interventions are very simple and easy to use and do not require an internet connection, and messages tend to be shorter and therefore less burdensome to read.
Participants suggested a number of factors that might influence engagement with mHealth interventions for prescription opioid tapering. In particular, participants expressed a desire to continue to receive care from their health care provider, pointing to the importance of ensuring that mHealth interventions are used as an adjunct to, rather than a replacement of, the patient-provider communication. Relatedly, some participants expressed concern that support received via text messages would feel impersonal or ingenuine. In response to this (common) concern, many mHealth interventions now personalize SMS text messaging content by, for example, addressing users by their preferred name or by tailoring messaging to the interests of the user (eg, “Hi Sam, doing things we enjoy helps us to feel good, so we feel less pain. Make plans to go for a hike, or perhaps meet a friend for coffee.”) These personalization strategies have been found to increase engagement with mHealth interventions [
Participants also indicated that their engagement with text messages may fluctuate and suggested that flexible message
Another method of tailoring the frequency of messages to user demands is to allow users to text prompts to the program when they wish to receive a message. The content of
Participants made 2 key recommendations for the content of an mHealth intervention to support people similar to them who were tapering opioids that were prescribed for CNCP. First, they recommended that users would benefit from messages about chronic pain management, opioid tapering, and strategies for coping with pain and withdrawal symptoms. This perspective concords with research demonstrating the positive association between giving patients informational or
At the same time, however, participants also noted that it may be difficult to understand and engage with information about coping with pain and symptoms of withdrawal via text if one does not already have some familiarity with these concepts. This concept is in line with previous research that demonstrated reduced opioid medication use in a group of patients who received automated telephone voice messages following an 11-week group pain management program [
Participants also suggested that messages offering social or emotional support may be beneficial and expressed a need for encouragement and validation. This is consistent with research demonstrating that validation—having one’s feelings and experience acknowledged without judgment—significantly reduces distress, elevates positive mood, and increases pain tolerance [
A key limitation of this study is that participants reported their
We acknowledge that the interview guide contained prompt questions that were closed ended (eg, “Would you be interested in receiving SMS messages with informative and supportive content when you are reducing your opioid medication?”). Although interviewers were trained to follow up any closed-ended questions with an open-ended question, it is possible that closed-ended or leading questions may have biased patients’ responses.
This study was conducted within the context of a larger study, which determined the sample size of this study. Certainly, the results of our descriptive (quantitative) survey would be strengthened with further sampling. However, the goal of qualitative data collection was to canvas a variety of perspectives on mHealth support for opioid tapering rather than to evaluate the proportion of people living with chronic pain who share certain perspectives. For this purpose, our sample size was adequate.
This study was conducted before the COVID-19 pandemic in Australia. As a result of the pandemic and associated social distancing measures, Australians have become more familiar with digital health technologies (ie, telehealth). It is possible that in the interests of maintaining social distancing and leveraging some of the efficiencies of digitally delivered health care, Australians may be more willing to engage with digital health interventions now more than ever.
The results of this study will be used to inform the development of a user-centered mHealth intervention to support people who are tapering prescription opioids for CNCP. Consistent with the existing guidelines for the development of mHealth interventions, the next stage of our research will involve co-designing and testing of intervention content (messages) in partnership with clinical experts as well as end users [
Summary of perceived barriers to and facilitators of patients’ engagement with implications for mobile health design, functionality, and content.
Theme | Implication | Recommendation | |||
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Internet access | Functionality | SMS text messaging–based intervention may be more feasible than app-based intervention for this population | ||
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Access to smartphone technology | Functionality | SMS text messaging–based intervention may be more feasible than app-based intervention for this population | ||
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Digital literacy or confidence in using SMS text messaging versus apps | Design and functionality | SMS text messaging–based intervention may be more feasible than app-based intervention for this population | ||
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Vision impairment | Design | SMS text messaging–based intervention may be more feasible than app-based intervention for this population | ||
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Reservation about app use | Design | SMS text messaging–based intervention may be more feasible than app-based intervention for this population | ||
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Maintaining contact with health care provider | Functionality | Communicate to users that the purpose of the intervention is to provide support in addition to that delivered by the health care provider | ||
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Fluctuating dose (support) needs | Design | User controls frequency of messaging after an initial |
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Fluctuating content needs | Functionality | User can request support with specific issues by texting keywords to the server (eg, “crave,” “anxious,” or “pain”) | ||
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Familiarity with pain management strategies | Design | Standardized pre-education may be needed to ensure that patients have a basic understanding of pain management and reasons for opioid tapering before they receive supportive messages | ||
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Desire for individualized care | Functionality and content | Personalization of SMS text messaging content. Use of name and message tailored to demographic details of user | ||
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Predictability | Functionality | Variability in the time of day the messages are sent can increase attention and engagement | ||
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Socioemotional reassurance | Content | Validating message content that aims to normalize concerns that participants may have in their tapering (eg, “It’s natural to worry about pain increasing”) | ||
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Informational reassurance | Content | Informational message content to educate on nonopioid pain management (eg, “opioids are proven to relieve acute pain but not chronic pain”) |
The results of this study indicate that patients with CNCP expressed interest in engaging with an mHealth intervention to support prescription opioid tapering. Interviews with this diverse group of potential users revealed barriers to feasibility and acceptability to be addressed and offered insights into factors that may increase engagement with this mHealth intervention. Future research will evaluate whether mHealth interventions improve patients’ confidence in their ability to manage their pain and maintain their quality of life while tapering opioid medications.
Survey and semistructured interview guide.
chronic noncancer pain
mobile health
None declared.