Care Models to Improve Pain and Reduce Opioids Among Patients Prescribed Long-Term Opioid Therapy
Authors: Krebs Erin E. , Becker William C. , Nelson David B. , DeRonne Beth M. , Jensen Agnes C. , Kats Allyson M. , Morasco Benjamin J. , Frank Joseph W. , Makris Una E. , Allen Kelli D. , Naylor Jennifer C. , Mixon Amanda S. , Bohnert Amy , Reznik Thomas E. , Painter Jacob T. , Hudson Teresa J. , Hagedorn Hildi J. , Manuel Jennifer K. , Borsari Brian , Purcell Natalie , Hammett Patrick , Amundson Erin C. , Kerns Robert D. , Barbosa Monica R. , Garvey Caitlin , Jones Elzie J. , Noh Maureen Y. , Okere Jennifer B. , Bhushan Sujata , Pinsonnault John , Williams Beth E. , Herbst Ellen , Lagisetty Pooja , Librodo Sara , Mapara Payal S. , Son Elizabeth , Tat Christina , Marraffa Rebecca A. , Seys Randy L. , Baxley Catherine , Seal Karen H. ,   VOICE Study Group, Abelleira Audrey , Adams Melissa , Anicich Adam , Ankawi Brett , Arnold Stephanie , Aryal Anuj , Atkins David , Atkinson Timothy , Backe Kristen , Bair Matthew , Bajpai Smita , Baller Kristeen , Bangerter Ann , Barnett Steven , Bartlett Stephen , Bartnik Mary K. , Baskin Joel , Blehm Ronald , Bloechl Philip P. , Boening Natassia , Boesch Nicole , Bolander Sondra , Bolf Marianne , Bonchak John , Booth Karen , Bordanea Margaret , Borowa Dominika , Bowden Marnie , Britnell Sara , Broderick Daniel , Bronars Carrie , Brooks Koren , Brown Cheryl B. , Brudvik Erin , Buchanan Katrina , Buesgens Carolyn , Buonora Michele , Burch Rebekka , Burton Caitlin , Butler Celia A. , Byerly Susan , Byrd Catherine , Byrd Gina , Campbell Emily , Cariveau Desmond , Carmody Suzanne , Carr Medenna , Carr Thomas , Cervone Dana , Chandler Michael , Clarke Kendra , Clay Michael , Coy William B. , Craine Michael , Culver David , Cutting Andrea , Dadabayev Alisher , Daly David , Degerstrom Rose , Denietolis Angela L. , DePesa Natasha , Desmet Paula , Devlin Amber , Dike Dozie , Diokpa Chinedu , Dogra Meenakshi , Drexler Karen , Drum-Oden Anna , Duvall Tina , Eads Frances K. , Edmond Sara N. , Eichelsdoerfer Edward , Ellifritz Christina , Ellison Jenna , Erwin Kimberly , Escobedo Christi , Feighner Lydia , Feuchs Ashley , Fike Ashley , Finetti Toni , Franchina Livia , Freeman John T. , Frontera Rebecca A. , Galvan Rachel , Gayle Sherrhonda , Givens Courtney , Glenn Rosie , Godwin Keely , Goldstein Michael , Gosselin Kelly , Graham Stephen , Grimm Kimberlea F. , Gumidyala Amitha , Hagerman Christine , Hale Anne , Hall Levi M. , Harden Jacqueline , Hawkins Jeanette , Hepton Stephanie , Herynk Aleks , Heuermann Brandon , Hidalgo Nina , Hoffmann John , Holland-deguire Christopher , Hope Kaydance , Horowitz Dana , Huang Andre , Huffman Katie F. , Hunt Neal E. , Hyde Stephanie , Jacobson Kristi , Johnson Eric , Kaiser Betty , Kauzlarich Kimberly , Kavathekar Rahul , Knutson Rena , Kross Tawny , LaHaie Edward , Lahidji Sam , Le Grace , Lelovic Mira , Lewis Martein , Linden Erin , Lindsay David , Lively-Brindley Lisa , Lorenzo Janet , Luciani Lisa , Lusk Cassie , Mahal-Lichty Jill , Maloy Patricia , Marcolivio Kimberly , Marcy Bradley , Marek Lindsay , Mason Bindu , McCamish Nicole , McKissack Michael , Miller Elaine , Moon Janis , Morris Heidi , Mundt Jennifer , Nazario Mitchell , Nelson Angela , Nichols Angela , Njau Esther , Nolan Charlotte , Nolan Patricia , Nugent Sean , Oakley Joshua W. , Ofstad Helen , Olney Ronald L. , Olson Jed , Ortolan Veronica , Osborne Jeffrey , Osler Bruce , Packard-Milam Michele , Palyo Sarah , Patel Anjali , Wiener Chelsea H. , Peter Doris , Philippe Michel , Reddy Saritha , Reed Justin , Rettmann Nancy , Rezaei David , Roberti Alyssa , Robinson Verona , Roca Henri , Romano Eleni , Rosema Tara , Rouse Robert , Rozzero Paul , Rutks Indulis , Sabet Raha F , Sacra Elijah , Sadowski Nicole , Salameh Hope , Sandbrink Friedhelm , Sauve Clarke , Schopmeyer Kathryn A. , Schroeder Allison , Sculley Megan , Sellinger John , Sewell Kenneth , Shah Barman Mona , Sharpe Pamela , Sides Tracy , Silver Kristin E. , Siver Malloree , Sloan Jessica , Smith Christine , Stevens Sean , Stoll Jennifer , Stoll Sandra , Stoner Thomas , Strand Malcolm , Sumner Jean A. , Surginer Bobby , Svabek Kaitlin , Swanson Gina , Tappainer Carla , Taylor Brent C. , Theis Alec , Thomas Laura C. , Thomas Gay R , Tiene Kathryn , Udouj Randall , Ugbo Ebonne , Varughese Shaina R. , Venkatraman Shanti , Viera Katherine , Walker Janet , Walker Jennifer , Wang Gloria , Watson Kayleen , Watson Erin , Westmoreland William C. , Wilbur Eileen , Wolfman Alan , Woloszyn Melinda , Zanga Joseph , Zuniga Samara 
Published: December 2024

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 &amp;lt; .001) in IPT and from 6.6 (1.6) points to 6.0 (1.9) points (P &amp;lt; .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 &amp;lt; .001) and from 74.5 (56.9) mg/d to 52.8 (51.9) mg/d (P &amp;lt; .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