Eboni G Price-Haywood, Jeffrey H Burton, Jewel Harden-Barrios, Alessandra Bazzano, Lizheng Shi, John Lefante, Robert N Jamison
{"title":"减少合并慢性疼痛、抑郁和焦虑的大剂量阿片类药物的决策支持和行为健康：阶梯式楔形集群随机试验》。","authors":"Eboni G Price-Haywood, Jeffrey H Burton, Jewel Harden-Barrios, Alessandra Bazzano, Lizheng Shi, John Lefante, Robert N Jamison","doi":"10.1007/s11606-024-08965-7","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors.</p><p><strong>Objective: </strong>Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions.</p><p><strong>Design: </strong>Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA.</p><p><strong>Participants: </strong>Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls.</p><p><strong>Intervention: </strong>EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management.</p><p><strong>Main measures: </strong>Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation.</p><p><strong>Key results: </strong>Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants.</p><p><strong>Conclusions: </strong>Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov ID NCT03889418.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2952-2960"},"PeriodicalIF":4.3000,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576687/pdf/","citationCount":"0","resultStr":"{\"title\":\"Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial.\",\"authors\":\"Eboni G Price-Haywood, Jeffrey H Burton, Jewel Harden-Barrios, Alessandra Bazzano, Lizheng Shi, John Lefante, Robert N Jamison\",\"doi\":\"10.1007/s11606-024-08965-7\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors.</p><p><strong>Objective: </strong>Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions.</p><p><strong>Design: </strong>Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA.</p><p><strong>Participants: </strong>Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls.</p><p><strong>Intervention: </strong>EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management.</p><p><strong>Main measures: </strong>Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation.</p><p><strong>Key results: </strong>Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants.</p><p><strong>Conclusions: </strong>Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov ID NCT03889418.</p>\",\"PeriodicalId\":15860,\"journal\":{\"name\":\"Journal of General Internal Medicine\",\"volume\":\" \",\"pages\":\"2952-2960\"},\"PeriodicalIF\":4.3000,\"publicationDate\":\"2024-11-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576687/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Journal of General Internal Medicine\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1007/s11606-024-08965-7\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"2024/8/2 0:00:00\",\"PubModel\":\"Epub\",\"JCR\":\"Q1\",\"JCRName\":\"HEALTH CARE SCIENCES & SERVICES\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of General Internal Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1007/s11606-024-08965-7","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/8/2 0:00:00","PubModel":"Epub","JCR":"Q1","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial.
Background: High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors.
Objective: Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions.
Design: Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA.
Participants: Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls.
Intervention: EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management.
Main measures: Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation.
Key results: Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants.
Conclusions: Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain.
Trial registration: ClinicalTrials.gov ID NCT03889418.
期刊介绍：
The Journal of General Internal Medicine is the official journal of the Society of General Internal Medicine. It promotes improved patient care, research, and education in primary care, general internal medicine, and hospital medicine. Its articles focus on topics such as clinical medicine, epidemiology, prevention, health care delivery, curriculum development, and numerous other non-traditional themes, in addition to classic clinical research on problems in internal medicine.
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