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
{"title":"Care Models to Improve Pain and Reduce Opioids Among Patients Prescribed Long-Term Opioid Therapy: The VOICE Randomized Clinical Trial.","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","doi":"10.1001/jamainternmed.2024.6683","DOIUrl":null,"url":null,"abstract":"<p><strong>Importance: </strong>Patients prescribed long-term opioid therapy for chronic pain often experience unrelieved pain, poor quality of life, and serious adverse events.</p><p><strong>Objective: </strong>To compare the effects of integrated pain team (IPT) vs pharmacist collaborative management (PCM) on pain and opioid dosage.</p><p><strong>Design, setting, and participants: </strong>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).</p><p><strong>Interventions: </strong>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.</p><p><strong>Main outcomes and measures: </strong>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.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions and relevance: </strong>Outcomes in this randomized clinical trial did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT03026790.</p>","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5000,"publicationDate":"2024-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"JAMA Internal Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1001/jamainternmed.2024.6683","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"MEDICINE, GENERAL & INTERNAL","Score":null,"Total":0}
引用次数: 0
Abstract
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.
期刊介绍：
JAMA Internal Medicine is an international, peer-reviewed journal committed to advancing the field of internal medicine worldwide. With a focus on four core priorities—clinical relevance, clinical practice change, credibility, and effective communication—the journal aims to provide indispensable and trustworthy peer-reviewed evidence.
Catering to academics, clinicians, educators, researchers, and trainees across the entire spectrum of internal medicine, including general internal medicine and subspecialties, JAMA Internal Medicine publishes innovative and clinically relevant research. The journal strives to deliver stimulating articles that educate and inform readers with the latest research findings, driving positive change in healthcare systems and patient care delivery.
As a member of the JAMA Network, a consortium of peer-reviewed medical publications, JAMA Internal Medicine plays a pivotal role in shaping the discourse and advancing patient care in internal medicine.
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