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Care Models to Improve Pain and Reduce Opioids Among Patients Prescribed Long-Term Opioid Therapy

2024; American Medical Association; Linguagem: Inglês

10.1001/jamainternmed.2024.6683

2168-6114

Erin E. Krebs, William C. Becker, David Nelson, Beth DeRonne, Agnes Jensen, Allyson M. Kats, Benjamin J. Morasco, Joseph W. Frank, Una E. Makris, Kelli D. Allen, Jennifer C. Naylor, Amanda S. Mixon, Amy M. Bohnert, Thomas E. Reznik, Jacob T. Painter, Teresa J. Hudson, Hildi Hagedorn, Jennifer K. Manuel, Brian Borsari, Natalie Purcell, Patrick Hammett, Erin C. Amundson, Robert D. Kerns, Monica R. Barbosa, Caitlin Garvey, Ervin E. Jones, Maureen Y. Noh, Jennifer B. Okere, Sujata Bhushan, John Pinsonnault, Beth E. Williams, Ellen Herbst, Pooja Lagisetty, Sara Librodo, Payal S. Mapara, Elizabeth Son, Christina Tat, Rebecca A. Marraffa, Randy L. Seys, Catherine Baxley, Karen H. Seal, Audrey Abelleira, Melissa Adams, Adam Anicich, Brett Ankawi, Stephanie Arnold, Anuj Aryal, David C. Atkins, Timothy Atkinson, Kristen Backe, Matthew J. Bair, Surabhi Bajpai, Kristeen Baller, Ann Bangerter, Steven Barnett, Stephen T. Bartlett, M. Bartnik, Jonathan J. Baskin, Ronald Blehm, Philip P. Bloechl, Natassia Boening, Nicole Boesch, Sondra Bolander, Marianne Bolf, John Bonchak, Karen Booth, Margaret Bordanea, Dominika Borowa, Marnie Bowden, Sally Britnell, Daniel F. Broderick, Carrie Bronars, Kristen Brooks, Cheryl Brown, Erin A. Brudvik, Katrina Buchanan, Carolyn Buesgens, Michele Buonora, Ronald M. Burch, Caitlin Burton, Christopher Butler, Susan Byerly, Catherine Byrd, G. Vernon Byrd, Emily M. Hagel Campbell, Desmond Cariveau, Suzanne Carmody, Medenna Carr, Thomas Carr, Dana Cervone, Michael J. Chandler, K.W. Clarke, Michael Clay, William B. Coy, Michael Craine, David H. Culver, Andrea Cutting, Alisher R. Dadabayev, David Daly, Rose Degerstrom, Angela Denietolis, Natasha S. DePesa, P. Desmet, Anita Devlin, Dozie Dike, Chinedu Diokpa, Meenakshi Dogra, Karen Drexler, Anna Drum-Oden, Tina Duvall, Frances K. Eads, Sara N. Edmond, Edward Eichelsdoerfer, Christina Ellifritz, Jenna Ellison, Kimberly Erwin, Carlos Escobedo, Lydia Feighner, Ashley Feuchs, Ashley Fike, Toni Finetti, Livia Franchina, John Taylor Freeman, Rebecca A. Frontera, R Galván, Sherrhonda Gayle, Courtney Givens, Rosie Glenn, K. David Godwin, Michael Goldstein, Kelly Gosselin, Stephen M. Graham, Kimberlea Grimm, Amitha Gumidyala, Christine Hagerman, Anne S. Hale, Levi M. Hall, Jacqueline Harden, Jeanette Hawkins, Stephanie Hepton, Aleks Herynk, Brandon Heuermann, Nina Hidalgo, John F. Hoffmann, Christopher Holland-deguire, Kaydance Hope, Dana Horowitz, Andre Huang, Katie F. Huffman, Nigel Hunt, Stephanie Hyde, Kathleen M. Jacobson, Eric S. Johnson, Brigitte Kaiser, Kimberly Kauzlarich, Rahul Kavathekar, Rena Knutson, Tawny Kross, Edward LaHaie, Sam Lahidji, Grace Le, Mira Lelovic, Michael B. Lewis, Eduardo Linden, David Lindsay, Lisa Lively-Brindley, Javier Deira, Lisa Luciani, Christine M. Lusk, Jill Mahal-Lichty, Patricia Maloy, Kimberly Marcolivio, Bradley Marcy, L. Marek, Brian A. Mason, Nicole McCamish, Michael McKissack, Elaine Hogan Miller, Janis Moon, Heidi Morris, Jennifer M. Mundt, Mitchell Nazario, Angela Nelson, Anna Nichols, Esther Njau, Charlotte Nolan, Patricia A. Nolan, Sean Nugent, Joshua W. Oakley, Helen Ofstad, Ronald L. Olney, Jed Olson, Veronica Ortolan, Jeffrey Osborne, Brian Osler, Michele Packard-Milam, Sarah A. Palyo, Anjali Patel, Chelsea Wiener, Doris Peter, Michel Philippe, Saranya Kumari Reddy, Justin Reed, Nancy A. Rettmann, David Rezaei, Andrea Roberti, Valencia Robinson, Henri Roca, Eleni Romano, Tara Rosema, Robert V. Rouse, Paul Rozzero, Indulis Rutks, Raheleh Sabetsarvestani, Elijah Sacra, N. Sadowski, Hope Salameh, Friedhelm Sandbrink, Caroline Sauvé, Kathryn Schopmeyer, Allison N. Schroeder, Megan Sculley, John Sellinger, Kenneth Sewell, Mona Shah Barman, Pamela L. Sharpe, Tracy Sides, K. Silver, Malloree Siver, Jessica Sloan, Christine Smith, Sean Stevens, Jennifer Stoll, Sandra Emily Stoll, Thomas Stoner, M. Strand, Jennifer A. Sumner, Bobby Surginer, Kaitlin Svabek, G. Marie Swanson, Carla Tappainer, Brent C Taylor, Alec Theis, Laura Thomas, Gay R Thomas, Kathryn Tiene, Randall Udouj, Ebonne Ugbo, S Varughese, Sonia Venkatraman, Katherine Viera, Janet Walker, Jennifer Walker, Gloria Wang, Kathryn Watson, Erin Watson, William C. Westmoreland, E. Lloyd Wilbur, Alan Wolfman, Melinda Woloszyn, Joseph R. Zanga, Samuel Torregrosa Zuñiga,

Musculoskeletal pain and rehabilitation

Importance Patients prescribed long-term opioid therapy for chronic pain often experience unrelieved pain, poor quality of life, and serious adverse events. Objective To compare the effects of integrated pain team (IPT) vs pharmacist collaborative management (PCM) on pain and opioid dosage. Design, Setting, and Participants This study was a pragmatic multisite 12-month randomized comparative effectiveness trial with masked outcome assessment. Patients were recruited from October 2017 to March 2021; follow-up was completed June 2022. The study sites were Veterans Affairs primary care clinics. Eligible patients had moderate to severe chronic pain despite long-term opioid therapy (≥20 mg/d for at least 3 months). Interventions IPT involved interdisciplinary pain care planning, visits throughout 12 months with medical and mental health clinicians, and emphasis on nondrug therapies and motivational interviewing. PCM was a collaborative care intervention involving visits throughout 12 months with a clinical pharmacist care manager who conducted structured monitoring and medication optimization. Both interventions provided individualized pain care and opioid tapering recommendations to patients. Main Outcomes and Measures The primary outcome was pain response (≥30% decrease in Brief Pain Inventory total score) at 12 months. The main secondary outcome was 50% or greater reduction in opioid daily dosage at 12 months. Results A total of 820 patients were randomized to IPT (n = 411) or PCM (n = 409). Participants’ mean (SD) age was 62.2 (10.6) years, and 709 (86.5%) were male. A pain response was achieved in 58/350 patients in the IPT group (16.4%) vs 54/362 patients in the PCM group (14.9%) (odds ratio, 1.11 [95% CI, 0.74-1.67]; P = .61). A 50% opioid dose reduction was achieved in 102/403 patients in the IPT group (25.3%) vs 98/399 patients in the PCM group (24.6%) (odds ratio, 1.03 [95% CI, 0.75-1.42]; P = .85). Over 12 months, the mean (SD) Brief Pain Inventory total score improved from 6.7 (1.5) points to 6.1 (1.8) points ( P < .001) in IPT and from 6.6 (1.6) points to 6.0 (1.9) points ( P < .001) in PCM (between-group P = .82). Over 12 months, mean (SD) opioid daily dosage decreased from 80.8 (74.2) mg/d to 54.2 (65.0) mg/d in IPT ( P < .001) and from 74.5 (56.9) mg/d to 52.8 (51.9) mg/d ( P < .001) in PCM (between-group P = .22). Conclusions and Relevance Outcomes in this randomized clinical trial did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage. Trial Registration ClinicalTrials.gov Identifier: NCT03026790