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Center for Chronic Disease Outcomes Research

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PCORI

Comparative Effectiveness of Patient-Centered Strategies to Improve Pain Management and Opioid Safety for Veterans

Background and Significance:

Treatment with opioid pain medications (like hydrocodone and morphine) is common for severe pain, but studies show these medications may not always help and can cause serious problems, especially when taken at high doses. To help patients with chronic pain have better quality of life and avoid medication toxicity, health care teams need to find ways to help patients reduce opioid medication doses to safer levels while helping them manage their pain. Patients told us that to help bring down opioid pain medication doses, our focus should be on finding better pain care strategies first and dropping doses second, only if the patient is ready.

Study Aims:

We will test which of two pain treatment strategies is better for managing pain and helping patients reduce opioid medication doses. For patients on high opioid doses who want to reduce, we will also test whether offering an extra option for tapering down helps them succeed. Finally, we want to look at patients’ and providers’ experiences in the study so that if these treatments work, we will know the best ways to implement them more broadly.

Study Description:

We will compare two treatment strategies among patients with pain who are taking long-term opioid pain medications prescribed by VA healthcare facilities across the country. Patients who wish to enter the study will be assigned by chance to telecare collaborative management (TCM) or integrated pain team (IPT). TCM involves a pharmacist and supervising physician working together to find the best medication options for each individual patient. IPT uses a team approach delivered by a physician, psychologist, and physical therapist. IPT uses medications but focuses most on non-medication pain management options (such as exercise or talk therapies) to address not only the physical aspects of pain, but also the emotional and social aspects of pain.

All participants will be asked to stay in the study for 12 months. Patients for whom it would be unsafe to participate will not be invited to join. Patients who do join the study are free to withdraw at any time.  With either treatment strategy, TCM or IPT, participants will have individualized pain care tailored to their wants and needs. Participants on high opioid medication doses who want to reduce their opioid medication dose will be assigned by chance to get either a regular step-wise taper or a choice between a regular taper or switching to a different medication.

At the end of the study we will compare which treatment strategy, TCM versus ITP, worked better to (1) decrease pain severity and (2) reduce opioid pain medication dose. We will also track other outcomes that are important to patients. These include overall quality of life, sleep, fatigue, depression, anxiety, and side effects. We will also test to see whether participants with certain conditions did better than others so we can learn how to best treat patients in an individualized way.