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.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
I guess the interventions have significant cost and the results are not impressive. Newsworthy mainly to underline the difficulty of dealing with this important issue.
Physician rater
Administrators and policymakers too often assume one type of team approach is better than others in reducing pain levels and/or opioid burden among patients. Although this was a select demographic (presumably almost, if not all, veterans with the vast majority male), these data did not show one type of approach was superior to another; however, both intensive team-based approaches were of benefit. The bottom line is two-fold: neither approach was superior to the other and we need to invest (and incentivize) team-based higher-intensity pain management care modalities to better serve patients and our community.
, McMaster University