Care Models to Improve Pain and Reduce Opioids Among Patients Prescribed Long-Term Opioid Therapy
Authors: Erin E. Krebs, William C. Becker, David B. Nelson, Beth M. DeRonne, Agnes C. Jensen, Allyson M. Kats, Benjamin J. Morasco, Joseph W. Frank, Una E. Makris, Kelli D. Allen, Jennifer C. Naylor, Amanda S. Mixon, Amy Bohnert, Thomas E. Reznik, Jacob T. Painter, Teresa J. Hudson, Hildi J. Hagedorn, Jennifer K. Manuel, Brian Borsari, Natalie Purcell, Patrick Hammett, Erin C. Amundson, Robert D. Kerns, Monica R. Barbosa, Caitlin Garvey, Elzie J. 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 Atkins, Timothy Atkinson, Kristen Backe, Matthew Bair, Smita Bajpai, Kristeen Baller, Ann Bangerter, Steven Barnett, Stephen Bartlett, Mary K. Bartnik, Joel Baskin, Ronald Blehm, Philip P. Bloechl, Natassia Boening, Nicole Boesch, Sondra Bolander, Marianne Bolf, John Bonchak, Karen Booth, Margaret Bordanea, Dominika Borowa, Marnie Bowden, Sara Britnell, Daniel Broderick, Carrie Bronars, Koren Brooks, Cheryl B. Brown, Erin Brudvik, Katrina Buchanan, Carolyn Buesgens, Michele Buonora, Rebekka Burch, Caitlin Burton, Celia A. Butler, Susan Byerly, Catherine Byrd, Gina Byrd, Emily Campbell, Desmond Cariveau, Suzanne Carmody, Medenna Carr, Thomas Carr, Dana Cervone, Michael Chandler, Kendra Clarke, Michael Clay, William B. Coy, Michael Craine, David Culver, Andrea Cutting, Alisher Dadabayev, David Daly, Rose Degerstrom, Angela L. Denietolis, Natasha DePesa, Paula Desmet, Amber 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, Christi Escobedo, Lydia Feighner, Ashley Feuchs, Ashley Fike, Toni Finetti, Livia Franchina, John T. Freeman, Rebecca A. Frontera, Rachel Galvan, Sherrhonda Gayle, Courtney Givens, Rosie Glenn, Keely Godwin, Michael Goldstein, Kelly Gosselin, Stephen Graham, Kimberlea F. Grimm, Amitha Gumidyala, Christine Hagerman, Anne Hale, Levi M. Hall, Jacqueline Harden, Jeanette Hawkins, Stephanie Hepton, Aleks Herynk, Brandon Heuermann, Nina Hidalgo, John Hoffmann, Christopher Holland-deguire, Kaydance Hope, Dana Horowitz, Andre Huang, Katie F. Huffman, Neal E. Hunt, Stephanie Hyde, Kristi Jacobson, Eric Johnson, Betty Kaiser, Kimberly Kauzlarich, Rahul Kavathekar, Rena Knutson, Tawny Kross, Edward LaHaie, Sam Lahidji, Grace Le, Mira Lelovic, Martein Lewis, Erin Linden, David Lindsay, Lisa Lively-Brindley, Janet Lorenzo, Lisa Luciani, Cassie Lusk, Jill Mahal-Lichty, Patricia Maloy, Kimberly Marcolivio, Bradley Marcy, Lindsay Marek, Bindu Mason, Nicole McCamish, Michael McKissack, Elaine Miller, Janis Moon, Heidi Morris, Jennifer Mundt, Mitchell Nazario, Angela Nelson, Angela Nichols, Esther Njau, Charlotte Nolan, Patricia Nolan, Sean Nugent, Joshua W. Oakley, Helen Ofstad, Ronald L. Olney, Jed Olson, Veronica Ortolan, Jeffrey Osborne, Bruce Osler, Michele Packard-Milam, Sarah Palyo, Anjali Patel, Chelsea H. Wiener, Doris Peter, Michel Philippe, Saritha Reddy, Justin Reed, Nancy Rettmann, David Rezaei, Alyssa Roberti, Verona Robinson, Henri Roca, Eleni Romano, Tara Rosema, Robert Rouse, Paul Rozzero, Indulis Rutks, Raha F Sabet, Elijah Sacra, Nicole Sadowski, Hope Salameh, Friedhelm Sandbrink, Clarke Sauve, Kathryn A. Schopmeyer, Allison Schroeder, Megan Sculley, John Sellinger, Kenneth Sewell, Mona Shah Barman, Pamela Sharpe, Tracy Sides, Kristin E. Silver, Malloree Siver, Jessica Sloan, Christine Smith, Sean Stevens, Jennifer Stoll, Sandra Stoll, Thomas Stoner, Malcolm Strand, Jean A. Sumner, Bobby Surginer, Kaitlin Svabek, Gina Swanson, Carla Tappainer, Brent C. Taylor, Alec Theis, Laura C. Thomas, Gay R Thomas, Kathryn Tiene, Randall Udouj, Ebonne Ugbo, Shaina R. Varughese, Shanti Venkatraman, Katherine Viera, Janet Walker, Jennifer Walker, Gloria Wang, Kayleen Watson, Erin Watson, William C. Westmoreland, Eileen Wilbur, Alan Wolfman, Melinda Woloszyn, Joseph Zanga, Samara Zuniga
Journal: JAMA Internal Medicine (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;amp;lt; .001) in IPT and from 6.6 (1.6) points to 6.0 (1.9) points ( P &amp;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;amp;lt; .001) and from 74.5 (56.9) mg/d to 52.8 (51.9) mg/d ( P &amp;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