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Price-Haywood EG, Burton JH, Harden-Barrios J, Bazzano A, Shi L, Lefante J, Jamison RN. Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial. J Gen Intern Med 2024:10.1007/s11606-024-08965-7. [PMID: 39095571 DOI: 10.1007/s11606-024-08965-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/18/2024] [Indexed: 08/04/2024]
Abstract
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.
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Affiliation(s)
- Eboni G Price-Haywood
- Ochsner Xavier Institute for Health Equity and Research, Academic Center - 2nd Floor, 1401A Jefferson Highway, New Orleans, LA, 70121, USA.
- Center for Outcomes Research, 1401A Jefferson Highway, New Orleans, LA, 70121, USA.
- Ochsner Clinical School, University of Queensland, 1401A Jefferson Highway, New Orleans, LA, 70121, USA.
| | - Jeffrey H Burton
- Center for Outcomes Research, 1401A Jefferson Highway, New Orleans, LA, 70121, USA
| | - Jewel Harden-Barrios
- Ochsner Xavier Institute for Health Equity and Research, Academic Center - 2nd Floor, 1401A Jefferson Highway, New Orleans, LA, 70121, USA
- Center for Outcomes Research, 1401A Jefferson Highway, New Orleans, LA, 70121, USA
| | - Alessandra Bazzano
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, 70112, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, 70112, USA
| | - John Lefante
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, 70112, USA
| | - Robert N Jamison
- Brigham and Women's Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA, 02467, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
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Coffee Z, Cheng K, Slebodnik M, Mulligan K, Yu CH, Vanderah TW, Gordon JS. The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:794. [PMID: 38929040 PMCID: PMC11203961 DOI: 10.3390/ijerph21060794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/06/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.
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Affiliation(s)
- Zhanette Coffee
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
| | - Kevin Cheng
- College of Medicine, University of Arizona, Tucson, AZ 85721, USA;
| | | | - Kimberly Mulligan
- Veterans Health Administration, Central California, Fresno, CA 93706, USA
| | - Chong Ho Yu
- Department of Mathematics, Hawaii Pacific University, Honolulu, HI 96813, USA;
| | - Todd W. Vanderah
- Department of Pharmacology, Comprehensive Center for Pain and Addiction, University of Arizona, Tucson, AZ 85721, USA;
| | - Judith S. Gordon
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
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Goetschi AN, Meyer-Massetti C. Characterising pharmacists' interventions in chronic non-cancer pain care: a scoping review. Int J Clin Pharm 2024:10.1007/s11096-024-01741-x. [PMID: 38861043 DOI: 10.1007/s11096-024-01741-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/08/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Chronic non-cancer pain may affect up to 51% of the general population. Pharmacist interventions have shown promise in enhancing patient safety and outcomes. However, our understanding of the scope of pharmacists' interventions remains incomplete. AIM Our goal was to characterise pharmacists' interventions for the management of chronic non-cancer pain. METHOD Medline, Embase, PsycINFO via Ovid, CINAHL via EBSCO databases and the Cochrane Library were systematically searched. Abstracts and full texts were independently screened by two reviewers. Data were extracted by one reviewer, and validated by the second. Outcomes of studies were charted using the dimensions of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). RESULTS Forty-eight reports were included. Interventions ensuring appropriate drug prescription occurred in 37 (79%) studies. Patient education and healthcare professional education were reported in 28 (60%) and 5 (11%) studies, respectively. Therapy monitoring occurred in 17 (36%) studies. Interventions regularly involved interprofessional collaboration. A median of 75% of reported outcome domains improved due to pharmacist interventions, especially patient disposition (adherence), medication safety and satisfaction with therapy. CONCLUSION Pharmacists' interventions enhanced the management of chronic non-cancer pain. Underreported outcome domains and interventions, such as medication management, merit further investigation.
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Affiliation(s)
- Aljoscha Noël Goetschi
- Clinical Pharmacology and Toxicology, General Internal Medicine, University Hospital of Bern, Anna-Von-Krauchthal-Weg 7, 3010, Bern, Switzerland.
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Carla Meyer-Massetti
- Clinical Pharmacology and Toxicology, General Internal Medicine, University Hospital of Bern, Anna-Von-Krauchthal-Weg 7, 3010, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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4
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Green T, Bosworth HB, Coronado GD, DeBar L, Green BB, Huang SS, Jarvik JG, Mor V, Zatzick D, Weinfurt KP, Check DK. Factors Affecting Post-trial Sustainment or De-implementation of Study Interventions: A Narrative Review. J Gen Intern Med 2024; 39:1029-1036. [PMID: 38216853 PMCID: PMC11074060 DOI: 10.1007/s11606-023-08593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024]
Abstract
In contrast to traditional randomized controlled trials, embedded pragmatic clinical trials (ePCTs) are conducted within healthcare settings with real-world patient populations. ePCTs are intentionally designed to align with health system priorities leveraging existing healthcare system infrastructure and resources to ease intervention implementation and increase the likelihood that effective interventions translate into routine practice following the trial. The NIH Pragmatic Trials Collaboratory, funded by the National Institutes of Health (NIH), supports the conduct of large-scale ePCT Demonstration Projects that address major public health issues within healthcare systems. The Collaboratory has a unique opportunity to draw on the Demonstration Project experiences to generate lessons learned related to ePCTs and the dissemination and implementation of interventions tested in ePCTs. In this article, we use case studies from six completed Demonstration Projects to summarize the Collaboratory's experience with post-trial interpretation of results, and implications for sustainment (or de-implementation) of tested interventions. We highlight three key lessons learned. First, ineffective interventions (i.e., ePCT is null for the primary outcome) may be sustained if they have other measured benefits (e.g., secondary outcome or subgroup) or even perceived benefits (e.g., staff like the intervention). Second, effective interventions-even those solicited by the health system and/or designed with significant health system partner buy-in-may not be sustained if they require significant resources. Third, alignment with policy incentives is essential for achieving sustainment and scale-up of effective interventions. Our experiences point to several recommendations to aid in considering post-trial sustainment or de-implementation of interventions tested in ePCTs: (1) include secondary outcome measures that are salient to health system partners; (2) collect all appropriate data to allow for post hoc analysis of subgroups; (3) collect experience data from clinicians and staff; (4) engage policy-makers before starting the trial.
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Affiliation(s)
- Terren Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
- Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | | | - Lynn DeBar
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Susan S Huang
- Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA.
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Wartko PD, Krakauer C, Turner JA, Cook AJ, Boudreau DM, Sullivan MD. STRategies to Improve Pain and Enjoy life (STRIPE): results of a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy. Pain 2023; 164:2852-2864. [PMID: 37624901 PMCID: PMC10843637 DOI: 10.1097/j.pain.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/19/2023] [Indexed: 08/27/2023]
Abstract
ABSTRACT Because long-term opioid therapy (LtOT) for chronic pain has uncertain benefits and dose-dependent harms, safe and effective strategies for opioid tapering are needed. Adapting a promising pilot study intervention, we conducted the STRategies to Improve Pain and Enjoy life (STRIPE) pragmatic clinical trial. Patients in integrated health system on moderate-to-high dose of LtOT for chronic noncancer pain were randomized individually to usual care plus intervention (n = 79) or usual care only (n = 74). The intervention included pain coping skills training and optional support for opioid taper, delivered in 18 telephone sessions over a year, with pharmacologic guidance provided to participants' primary care providers by a pain physician. Coprimary outcomes were daily opioid dose (morphine milligram equivalent [MME]), calculated using pharmacy dispensing data, and the self-reported Pain, Enjoyment of Life and General Activity scale at 12 months (primary time point) and 6 months. Secondary outcomes included opioid misuse, opioid difficulties, opioid craving, pain self-efficacy, and global impression of change, depression, and anxiety. Only 41% randomized to the intervention completed all sessions. We did not observe significant differences between intervention and usual care for MME (adjusted mean difference: -2.3 MME; 95% confidence interval: -10.6, 5.9; P = 0.578), the Pain, Enjoyment of Life, General Activity scale (0.0 [95% confidence interval: -0.5, 0.5], P = 0.985), or most secondary outcomes. The intervention did not lower opioid dose or improve pain or functioning. Other strategies are needed to reduce opioid doses while improving pain and function for patients who have been on LtOT for years with high levels of medical, mental health, and substance use comorbidity.
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
| | - Judith A. Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States of America
| | - Andrea J. Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Denise M. Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
- Genentech, Inc., South San Francisco, CA, United States of America (current primary affiliation)
| | - Mark D. Sullivan
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
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Witkiewitz K, Vowles KE. Everybody Hurts: Intersecting and Colliding Epidemics and the Need for Integrated Behavioral Treatment of Chronic Pain and Substance Use. CURRENT DIRECTIONS IN PSYCHOLOGICAL SCIENCE 2023; 32:228-235. [PMID: 37645017 PMCID: PMC10465109 DOI: 10.1177/09637214231162366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Chronic pain and substance use disorders are both common, debilitating, and often persist over the longer term. On their own, each represents a significant health problem, with estimates indicating a substantial proportion of the adult population has chronic pain or a substance use disorder (SUD), and their co-occurrence is increasing. Chronic pain and SUD are also both often invisible, stigmatized disorders and persons with both regularly have difficulty accessing evidence-based treatments, particularly those that offer coordinated and integrated treatment for both conditions. But there is hope. Research is unraveling the mechanisms of chronic pain and substance use, as well as their co-occurrence, integrated behavioral treatment options based on acceptance- and mindfulness-based approaches are increasingly being developed and tested, government agencies are devoting more funds and resources to increase research on chronic pain and SUD, and there have been growing efforts in training, dissemination, and implementation of evidence-based treatments. At the very heart of the matter, though, is to recognize that everybody hurts sometimes, and treatments must empower people to life effectively with these experiences of being human.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology and Center on Alcohol, Substance use, And Addictions University of New Mexico
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Mayhew M, Balderson BH, Cook AJ, Dickerson JF, Elder CR, Firemark AJ, Haller IV, Justice M, Keefe FJ, McMullen CK, O'Keeffe-Rosetti MC, Owen-Smith AA, Rini C, Schneider JL, Von Korff M, Wandner LD, DeBar LL. Comparing the clinical and cost-effectiveness of remote (telehealth and online) cognitive behavioral therapy-based treatments for high-impact chronic pain relative to usual care: study protocol for the RESOLVE multisite randomized control trial. Trials 2023; 24:196. [PMID: 36927459 PMCID: PMC10018633 DOI: 10.1186/s13063-023-07165-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/13/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Cognitive behavioral therapy for chronic pain (CBT-CP) is an effective but underused treatment for high-impact chronic pain. Increased access to CBT-CP services for pain is of critical public health importance, particularly for rural and medically underserved populations who have limited access due to these services being concentrated in urban and high income areas. Making CBT-CP widely available and more affordable could reduce barriers to CBT-CP use. METHODS As part of the National Institutes of Health Helping to End Addiction Long-term® (NIH HEAL) initiative, we designed and implemented a comparative effectiveness, 3-arm randomized control trial comparing remotely delivered telephonic/video and online CBT-CP-based services to usual care for patients with high-impact chronic pain. The RESOLVE trial is being conducted in 4 large integrated healthcare systems located in Minnesota, Georgia, Oregon, and Washington state and includes demographically diverse populations residing in urban and rural areas. The trial compares (1) an 8-session, one-on-one, professionally delivered telephonic/video CBT-CP program; and (2) a previously developed and tested 8-session online CBT-CP-based program (painTRAINER) to (3) usual care augmented by a written guide for chronic pain management. Participants are followed for 1 year post-allocation and are assessed at baseline, and 3, 6, and 12 months post-allocation. The primary outcome is minimal clinically important difference (MCID; ≥ 30% reduction) in pain severity (composite of pain intensity and pain-related interference) assessed by a modified 11-item version of the Brief Pain Inventory-Short Form at 3 months. Secondary outcomes include pain severity, pain intensity, and pain-related interference scores, quality of life measures, and patient global impression of change at 3, 6, and 12 months. Cost-effectiveness is assessed by incremental cost per additional patient with MCID in primary outcome and by cost per quality-adjusted life year achieved. Outcome assessment is blinded to group assignment. DISCUSSION This large-scale trial provides a unique opportunity to rigorously evaluate and compare the clinical and cost-effectiveness of 2 relatively low-cost and scalable modalities for providing CBT-CP-based treatments to persons with high-impact chronic pain, including those residing in rural and other medically underserved areas with limited access to these services. TRIAL REGISTRATION ClinicalTrials.gov NCT04523714. This trial was registered on 24 August 2020.
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Affiliation(s)
- Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, USA.
| | | | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | | | | | | | | | - Morgan Justice
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, USA
| | | | | | - Ashli A Owen-Smith
- Georgia State University and Center for Health Research and Evaluation Kaiser Permanente Georgia, Atlanta, USA
| | - Christine Rini
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, USA
| | | | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Laura D Wandner
- National Institute of Neurological Disorders and Stroke, Bethesda, USA
| | - Lynn L DeBar
- Kaiser Permanente Center for Health Research, Portland, USA
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Staman KL, Check DK, Zatzick D, Mor V, Fritz JM, Sluka K, DeBar LL, Jarvik JG, Volandes A, Coronado GD, Chambers DA, Weinfurt KP, George SZ. Intervention delivery for embedded pragmatic clinical trials: Development of a tool to measure complexity. Contemp Clin Trials 2023; 126:107105. [PMID: 36708968 PMCID: PMC10126825 DOI: 10.1016/j.cct.2023.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. METHODS We conducted a literature review, developed a tool, and conducted two rounds of phone calls with NIH Pragmatic Trials Collaboratory Demonstration Project principal investigators to develop the Intervention Delivery Complexity Tool. After refining the tool, we piloted it with Collaboratory demonstration projects and developed an online version of the tool using the R Shiny application (https://duke-som.shinyapps.io/ICT-ePCT/). RESULTS The 6-item tool consists of internal and external factors. Internal factors pertain to the intervention itself and include workflow, training, and the number of intervention components. External factors are related to intervention delivery at the system level including differences in healthcare systems, the dependency on setting for implementation, and the number of steps between the intervention and the outcome. CONCLUSION The Intervention Delivery Complexity Tool was developed as a standard way to overcome communication challenges of intervention delivery within an embedded pragmatic trial. This version of the tool is most likely to be useful to the trial team and its health system partners during trial planning and conduct. We expect further evolution of the tool as more pragmatic trials are conducted and feedback is received on its performance outside of the NIH Pragmatic Trials Collaboratory.
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Affiliation(s)
- Karen L Staman
- Duke Clinical Research Institute, CHB Wordsmith, Inc, Raleigh, NC, USA
| | - Devon K Check
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | | | - Kevin P Weinfurt
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, USA.
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Braverman MT, Volmar KM, Govier DJ. "The Pain Doesn't Have to Control You." A Qualitative Evaluation of Three Pain Clinics Teaching Nonopioid Pain Management Strategies. Am J Health Promot 2023; 37:210-221. [PMID: 36053192 DOI: 10.1177/08901171221119799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To explore factors related to effectiveness of nonpharmacological treatment for opioid-dependent patients suffering with chronic pain. APPROACH A qualitative study incorporating individual interviews and focus group interviews. SETTING 3 rural Oregon nonopioid pain management clinics. INTERVENTION A 10-week nonpharmacological educational program incorporating cognitive-behavioral therapy, movement therapy, mindfulness, and other skills. PARTICIPANTS AND METHODS Across sites, we conducted 9 individual interviews with clinic staff and 3 focus group interviews with 34 patients who had participated in the course. Thematic analysis was used to identify themes within and across respondent groups. RESULTS Analysis revealed 4 primary themes: program goals; program benefits; characteristics of patients who benefit from the program; coordination of clinic experiences with other care. Several primary findings can be highlighted. The clinics focused on improving patients' quality of life, while opioid use reduction was a potential secondary benefit, driven by patients. Major program benefits included enhanced pain self-management skills, patients' greater assertiveness in communications with healthcare providers, and, in numerous cases, opioid use reduction. Participants were unanimous that predisposition toward active self-management of one's pain was an essential factor for positive outcomes. Patients reported considerable variability in providers' understanding of their clinic participation. CONCLUSION Nonpharmacological approaches for treating chronic pain can be effective for many patients. Clinics teaching these approaches should be more fully integrated into the healthcare system.
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Affiliation(s)
- Marc T Braverman
- School of Social and Behavioral Health Sciences, 2694Oregon State University, Corvallis, OR, USA
| | - Karen M Volmar
- Department of Health Policy and Management, 41474University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Diana J Govier
- VA HSR&D Center to Improve Veteran Involvement in Care, Portland, OR, USA
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Helms J, Frankart L, Bradner M, Ebersole J, Regan B, Crouch T. Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231221950. [PMID: 38152832 PMCID: PMC10752086 DOI: 10.1177/23821205231221950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.
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Affiliation(s)
- Jeb Helms
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, USA
| | - Laura Frankart
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, USA
| | - Melissa Bradner
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, USA
| | | | - Beck Regan
- Virginia Commonwealth University, Richmond, USA
| | - Taylor Crouch
- Virginia Commonwealth University Health System, Richmond, USA
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Benes LL, Keefe FJ, DeBar LL. Treating Persistent Pain: A Nurse Co-Led, Interdisciplinary Model for Primary Care. Pain Manag Nurs 2022; 23:728-736. [PMID: 35922272 PMCID: PMC9771916 DOI: 10.1016/j.pmn.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/08/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
The public health crisis of chronic pain has only increased in recognition since the Institute of Medicine's (IOM) Relieving Pain in America (2011) called for a cultural transformation in the way pain is viewed, treated, and put forward specific recommendations for action. The National Pain Strategy (NPS) provides a roadmap for putting these recommendations into practice. We implemented a program that placed nurses and behavioral specialists at the head of an interdisciplinary team utilizing best practices. In this program, nurses enacted the NPS recommendations to advance care for patients with persistent pain on long-term opioid treatment. This program promoted professional growth in nurses along with fostering success for patients. Compared with patients receiving usual care, patients in the program achieved greater reductions in pain severity, pain-related disability, and pain-related functional interference and reported greater satisfaction with pain-related care and primary care services. This article will detail the NPS-aligned practice approaches these nurses and their teams used, describe the training for the nurses, and speak to opportunities to enhance the nurse's capacity for this role in hopes of providing a model for the future implementation of an NPS-based approach by nurses.
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Affiliation(s)
| | - Frank J Keefe
- Duke University, School of Medicine, Durham, North Carolina
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Bushey MA, Slaven JE, Outcalt SD, Kroenke K, Kempf C, Froman A, Sargent C, Baecher B, Zillich AJ, Damush TM, Saha C, French DD, Bair MJ. Effect of Medication Optimization vs Cognitive Behavioral Therapy Among US Veterans With Chronic Low Back Pain Receiving Long-term Opioid Therapy: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2242533. [PMID: 36394874 PMCID: PMC9672973 DOI: 10.1001/jamanetworkopen.2022.42533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Medication management and cognitive behavioral therapy (CBT) are commonly used treatments for chronic low back pain (CLBP). However, little evidence is available comparing the effectiveness of these approaches. OBJECTIVE To compare collaborative care medication optimization vs CBT on pain intensity, interference, and other pain-related outcomes. DESIGN, SETTING, AND PARTICIPANTS The Care Management for the Effective Use of Opioids (CAMEO) trial was a 12-month, comparative effectiveness randomized clinical trial with blinded outcome assessment. Recruitment of veterans with CLBP prescribed long-term opioids occurred at 7 Veterans Affairs primary care clinics from September 1, 2011, to December 31, 2014, and follow-up was completed December 31, 2015. Analyses were based on intention to treat in all randomized participants and were performed from March 22, 2015, to November 1, 2021. INTERVENTIONS Patients were randomized to receive either collaborative care with nurse care manager-delivered medication optimization (MED group) (n = 131) or psychologist-delivered CBT (CBT group) (n = 130) for 6 months, with check-in visits at 9 months and final outcome assessment at 12 months. MAIN OUTCOMES AND MEASURES The primary outcome was change in Brief Pain Inventory (BPI) total score, a composite of the pain intensity and interference subscales at 6 (treatment completion) and 12 (follow-up completion) months. Scores on the BPI range from 0 to 10, with higher scores representing greater pain impact and a 30% improvement considered a clinically meaningful treatment response. Secondary outcomes included pain-related disability, pain catastrophizing, self-reported substance misuse, health-related quality of life, depression, and anxiety. RESULTS A total of 261 patients (241 [92.3%] men; mean [SD] age, 57.9 [9.5] years) were randomized and included in the analysis. Baseline mean (SD) BPI scores in the MED and CBT groups were 6.45 (1.79) and 6.49 (1.67), respectively. Improvements in BPI scores were significantly greater in the MED group at 12 months (between-group difference, -0.54 [95% CI, -1.18 to -0.31]; P = .04) but not at 6 months (between-group difference, -0.46 [95% CI, -0.94 to 0.11]; P = .07). Secondary outcomes did not differ significantly between treatment groups. CONCLUSIONS AND RELEVANCE In this randomized clinical trial among US veterans with CLBP who were prescribed long-term opioid therapy, collaborative care medication optimization was modestly more effective than CBT in reducing pain impact during the 12-month study. However, this difference may not be clinically meaningful or generalize to nonveteran populations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01236521.
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Affiliation(s)
- Michael A. Bushey
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - James E. Slaven
- Department of Biostatistics and Heath Data Science, Indiana University School of Medicine, Indianapolis
| | - Samantha D. Outcalt
- Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Carol Kempf
- Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Amanda Froman
- Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Christy Sargent
- Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Brad Baecher
- Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Alan J. Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana
| | - Teresa M. Damush
- Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Chandan Saha
- Department of Biostatistics and Heath Data Science, Indiana University School of Medicine, Indianapolis
| | - Dustin D. French
- Department of Ophthalmology, Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Health Services and Outcomes Research, Chicago, Illinois
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Matthew J. Bair
- Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Inc, Indianapolis, Indiana
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Smith DH, O'Keeffe-Rosetti M, Leo MC, Mayhew M, Benes L, Bonifay A, Deyo RA, Elder CR, Keefe FJ, McMullen C, Owen-Smith A, Trinacty CM, Vollmer WM, DeBar L. Economic Evaluation: A Randomized Pragmatic Trial of a Primary Care-based Cognitive Behavioral Intervention for Adults Receiving Long-term Opioids for Chronic Pain. Med Care 2022; 60:423-431. [PMID: 35352703 PMCID: PMC9106895 DOI: 10.1097/mlr.0000000000001713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic pain is prevalent and costly; cost-effective nonpharmacological approaches that reduce pain and improve patient functioning are needed. OBJECTIVE Report the incremental cost-effectiveness ratio (ICER), compared with usual care, of cognitive behavioral therapy aimed at improving functioning and pain among patients with chronic pain on long-term opioid treatment. DESIGN Economic evaluation conducted alongside a pragmatic cluster randomized trial. SUBJECTS Adults with chronic pain on long-term opioid treatment (N=814). INTERVENTION A cognitive behavioral therapy intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorists, nurses) with additional support from physical therapists, and pharmacists. OUTCOME MEASURES Cost per quality adjusted life year (QALY) gained, and cost per additional responder (≥30% improvement on standard scale assessment of Pain, Enjoyment, General Activity, and Sleep). Costs were estimated as-delivered, and replication. RESULTS Per patient intervention replication costs were $2145 ($2574 as-delivered). Those costs were completely offset by lower medical care costs; inclusive of the intervention, total medical care over follow-up was $1841 lower for intervention patients. Intervention group patients also had greater QALY and responder gains than did controls. Supplemental analyses using pain-related medical care costs revealed ICERs of $35,000, and $53,000 per QALY (for replication, and as-delivered intervention costs, respectively); the ICER when excluding patients with outlier follow-up costs was $106,000. LIMITATIONS Limited to 1-year follow-up; identification of pain-related utilization potentially incomplete. CONCLUSION The intervention was the optimal choice at commonly accepted levels of willingness-to-pay for QALY gains; this finding was robust to sensitivity analyses.
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Affiliation(s)
- David H. Smith
- Kaiser Permanente Center for Health Research, Portland
OR
| | | | - Michael C. Leo
- Kaiser Permanente Center for Health Research, Portland
OR
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland
OR
| | - Lindsay Benes
- Kaiser Permanente Center for Health Research, Portland
OR
- Montana State University College of Nursing, Missoula,
MT
| | | | - Richard A. Deyo
- Oregon Health and Science University, School of Medicine,
Portland, OR
| | | | | | | | - Ashli Owen-Smith
- Georgia State University, School of Public Health, Atlanta
GA
- Kaiser Permanente Center for Clinical and Outcomes
Research, Atlanta GA
| | | | | | - Lynn DeBar
- Kaiser Permanente Washington Health Research Institute,
Seattle WA
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Parisi A, Landicho HL, Hudak J, Leknes S, Froeliger B, Garland EL. Emotional distress and pain catastrophizing predict cue-elicited opioid craving among chronic pain patients on long-term opioid therapy. Drug Alcohol Depend 2022; 233:109361. [PMID: 35278786 PMCID: PMC9466292 DOI: 10.1016/j.drugalcdep.2022.109361] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Individuals who use illicit substances exhibit cue-elicited craving and autonomic cue-reactivity when exposed to cues associated with past drug use. However, little is known about this phenomenon among chronic pain patients on long-term opioid therapy (LTOT). Negative cognitive-emotional reactivity in general (e.g., distress) and cognitive-emotional reactivity specific to pain (e.g., pain catastrophizing) might drive cue-reactivity independent of pain severity. Here we examined emotional distress and pain catastrophizing as predictors of cue-reactivity among a sample of chronic pain patients receiving LTOT. We also tested whether associations between distress, catastrophizing, and cue-reactivity differed as a function of opioid misuse status. MATERIALS AND METHODS Patients receiving LTOT (N = 243) were classified as exhibiting aberrant behavior consistent with opioid misuse (MISUSE+, n = 145) or as using opioids as prescribed (MISUSE-, n = 97). Participants completed assessments of pain catastrophizing and emotional distress and then participated in an opioid cue-reactivity task one week later. Cue-elicited opioid craving and autonomic cue-reactivity were measured with craving ratings and high-frequency heart rate variability (HRV), respectively. RESULTS Distress and catastrophizing predicted cue-elicited craving and HRV, whereas pain severity did not. Misuser status moderated the relationship between emotional distress and self-reported craving, such that higher levels of distress predicted craving among the MISUSE+ group, but not among the MISUSE- group. No moderating effects were found for catastrophizing. CONCLUSIONS Findings suggest that although opioids are prescribed for analgesia, the exacerbating influence of negative cognitive-emotional reactivity, both in general and specific to pain, on cue-elicited opioid craving extends beyond the effects of pain severity alone.
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Affiliation(s)
- Anna Parisi
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, USA; College of Social Work, University of Utah, USA
| | - Hannah Louise Landicho
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, USA; College of Social Work, University of Utah, USA
| | - Justin Hudak
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, USA; College of Social Work, University of Utah, USA
| | - Siri Leknes
- Department of Psychology, University of Oslo, USA
| | - Brett Froeliger
- Department of Psychiatry; Department of Psychological Sciences, University of Missouri, USA
| | - Eric L. Garland
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, USA; College of Social Work, University of Utah, USA
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Behavioral Health, Telemedicine, and Opportunities for Improving Access. Curr Pain Headache Rep 2022; 26:919-926. [PMID: 36418847 PMCID: PMC9684808 DOI: 10.1007/s11916-022-01096-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize advances in behavioral treatments for pain and headache disorders, as well as recent innovations in telemedicine for behavioral treatments. RECENT FINDINGS Research for behavioral treatments continues to support their use as part of a multidisciplinary approach to comprehensive management for pain and headache conditions. Behavioral treatments incorporate both behavioral change and cognitive interventions and have been shown to improve outcomes beyond that of medical management alone. The onset of the COVID-19 public health emergency necessitated the rapid uptake of nontraditional modalities for behavioral treatments, particularly telemedicine. Telemedicine has long been considered the answer to several barriers to accessing behavioral treatments, and as a result of COVID-19 significant progress has been made evaluating a variety of telemedicine modalities including synchronous, asynchronous, and mobile health applications. Researchers are encouraged to continue investigating how best to leverage these modalities to improve access to behavioral treatments and to continue evaluating the efficacy of telemedicine compared to traditional in-person care. Comprehensive pain and headache management should include behavioral treatments to address a variety of behavior change and cognitive targets. Policy changes and advances in telemedicine for behavioral treatments provide the opportunity to address historical barriers limiting access.
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