PONE-D-20-01387

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

PLOS ONE

Dear Dr. Sud,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Vijayaprakash Suppiah, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: A few comments which need attention:

Line 51-52, "Unintentional drug overdose deaths are high and on the rise throughout the Global North. The United..." --> Please define Global North for this article

Line 55-56, "One large socioeconomic effect of these epidemics is that life expectancies in the US and Canada have dropped over the last several years -->Please re-word to remove "dropped", perhaps say "decreased"

Line 78-79 "for tapering, or dose reduction. The Canadian guidelines provide a recommendation based on weak evidence --> Please better define or elaborate on "weak"

Line 139-140 "Grey literature was searched from a variety of sources including Ovid EMBASE (conference proceedings and meeting abstracts), -->Define "grey"

Line 183-184 "A data extraction form was created in Excel and tested by multiple reviewers. Once validated, the form was replicated in Covidence and data extraction was conducted singly. -->How many reviewers? how was it validated?

Line 367-368,"On the contrary, in American programs, where there are cultural and political concerns about opioid use, there were" -->please elaborate on "political concerns"

Line 476-477, "Interdisciplinary pain programs (IPPs) represent one of the best alternatives."

--> Throughout this paper the focus is on multidisciplinary, rather than interdisciplinary, approach to pain and opioid reduction. These are two different models and approaches to pain care, both with pros and cons. This article should specifically define these two, and explain why multidisciplinary versus interdisciplinary was chosen as the methodological approach.

Lines 543-546 "This could be operationalized in many ways, such as modified shared-care models which have been widely deployed to improve primary care access and capacity for mental health in Canada [134]. Likewise, persistent imbalances in institutional support (such as funding) -->

The authors should add some discussion about (1)payment reimbursement models, single payer systems versus private insurance payers from region to region, and how this might impact opioid tapering as well as patient and provider resources, treatments, incentives, and patient outcomes. In the US, there is a lack of incentive in this regard, thus discussing this for the US and other populations would be important as well as (2) lack of pain related education in medical schools and residencies which could also impact opioid tapering in various populations

Reviewer #2: Thank you for the opportunity to review the manuscript entitled "Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review". Overall, the manuscript is very well-written. It is also generally easy to follow the authors’ logic.

• A major point of constructive criticism lies with one of the main tenets of the review: Specifically, that effective programs (those that results in sustained reduction of opioid use), necessitate a “change in the opioid prescriber.” Although the “realist” portion of the review is understandably fraught with challenges for those who rely upon rigorous statistical analyses to generate hypotheses, this seems like an incorrect and far too simplistic conclusion.

• Based on the authors’ summaries, this seems much more like an issue of expertise, rather than a simple change in opioid prescriber/provider.

• The statement that “…results from this review are quite clear that such programs will not be effective in reducing opioid use unless there is a change in the primary opioid prescriber” (starting at line 541) seems unfounded.

• The authors more/less acknowledge that their conclusion may be oversimplified. For example by stating that the change in opioid use may be explained by a different mechanism, such as the referral process itself (see lines 387-388). Nonetheless, the authors go on to explicitly say that primary care should input a mechanism for changing providers, as if what was found in the review was a collective result of a simplistic, literal change in the person prescribing the opioid.

• A change in providers is accompanied by myriad other changes, including the potential for a change in the patient’s psyche as a result of the whole referral process, the patient’s orientation toward “getting well,” etc.

• The most important change that accompanies a change in provider however, appears to be a vast increase in the expertise of the providers. From this reviewer’s perspective, that should be the primary point, rather than a simple change in providers.

Minor points:

• It would be helpful to have a table with all 8 synthesis statements.

• The right side of Table 1 is cut off.

Reviewer #3: This is an excellent review and contribution to the literature of opioid use in patients with chronic pain.

I have a few minor questions and comments:

Page 2 line 63 reference? Please place reference here

Page 3 line 73-74, this sentence is unnecessarily accusatory. The opioid crisis is complicated it is not entirely iatrogenic.

Page 3, line 83-4, sentence is poorly written Page 3 line 94: do not capitalize the W in What

Table 1 did not fit on the page 8-13

Page w13: not sure that a program that ran for 1-5 days is in any way similar to longer running program. Please explain why this was included:

Page 14: Lines 229and 230. Confusing sentence

Page 15: Participants: We would expect different outcomes for patients with any form of opioid use disorder compared to those who are on chronic opioids for chronic pain. Please explasin why it is acceptable to lump them all together for the purposes of this study.

Page 17, line 299: Please define MPRP

Page 18, line 327: define COT-

Page 20-1, lines 376-378, “Some studies did report that higher proportions of non-completers were people on opioids…..” this is confusing, since the purported purpose of the this paper is to investigate the success of tapering opioids, why would the authors be looking at studies of patients who are not on opioids?

Page 21, line 381 clarify opiates versus opioids

Page 23, lines 434-436 Did any of the programs look at preexisting opioid use disorder?

Page 29-30. Excessively and unnecessarily long,

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Rita Agarwal

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PONE-D-20-01387R1

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

PLOS ONE

Dear Dr. Sud,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Please address the comments of the second reviewer. 

Thank you. 

==============================

Please submit your revised manuscript by Aug 13 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Vijayaprakash Suppiah, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors did a thorough and detailed review of my comments and did an excellent job addressing my feedback and updating their manuscript. It is now a thoughtful and well constructed piece which will add nicely the literature regarding clinical opioid management.

Reviewer #2: Overall, the authors did a good job of addressing reviewers' comments.

However, I continue to think that Summary Statement #5 is overly simplistic. In the example included on page 23, while the occupational therapist and social worker may have been experienced, neither was a pain physician. In the second example on page 23, it is unclear when a “different provider” (from page 23: “…however, the opioid prescribing was taken over by the different family physician…”) took over. Together, these two examples do not convince the reader that simplistically changing a provider would significantly reduce opioid consumption.

Perhaps clarifying or using different examples would help make the point?

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

PONE-D-20-01387R2

Dear Dr. Sud,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Vijayaprakash Suppiah, PhD

Academic Editor

PLOS ONE