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A randomized trial found that interdisciplinary care models modestly improved pain and significantly reduced opioid use in patients on long-term opioid therapy.

Collaborating interdisciplinary teams can reduce pain and opioid use in patients receiving long-term opioid therapy in primary care settings, according to findings from the VOICE randomized clinical trial published in JAMA Internal Medicine.

“Outcomes in this randomized comparative effectiveness trial did not differ between IPT [integrated pain team] and PCM [pharmacist collaborative management] groups. Both had small improvements in pain and substantial reductions in opioid dosage,” wrote lead author Erin E. Krebs, MD, MPH, and colleagues.

The researchers compared the effects of IPT with those of PCM on pain and opioid dosage in a 12-month, phase 2 trial with masked outcome assessment at 10 Veterans Affairs healthcare clinics.

Eligible participants, 709 (86.5%) of whom were male and whose mean age was 62.2 years, had moderate to severe chronic pain despite long-term opioid therapy of at least 20 mg/d for at least 3 months. Of the 820 participants recruited between 2017 and 2021 to receive individualized pain care and opioid tapering guidance, 411 were randomized to IPT and 409 to PCM. Follow-up continued to 2022.

Dr. Krebs and her colleagues found that both treatment groups had similar small improvements in pain and substantial decreases in opioid dosage:

• Fifty-eight of 350 patients (16.4%) in the IPT group versus 54 of 362 patients (14.9%) in the PCM group achieved a pain response (odds ratio [OR], 1.11; 95% CI, 0.74-1.67; P=0.61).
• One hundred two of 403 patients (25.3%) in the IPT group versus 98 of 399 patients (24.6%) in the PCM group achieved a 50% opioid dose reduction (OR, 1.03; 95% CI, 0.75-1.42; P=0.85).
• Over 12 months, the mean Brief Pain Inventory total score improved from 6.7 points to 6.1 points (P<0.001) in the IPT group and from 6.6 points to 6.0 points (P<0.001) in the PCM group (between-group P=0.82).
• Over 12 months, the mean daily opioid dosage decreased from 80.8 mg/d to 54.2 mg/d (P<0.001) in the IPT group and from 74.5 mg/d to 52.8 mg/d (P<0.001) in the PCM group (between-group P=0.22).

Natalie Klag, MD, a psychiatrist who was not involved in the study, talked with Physician’s Weekly (PW) about the study’s results and their potential impact on long-term opioid therapy.

PW: For clinicians, what are the study’s most important findings?

Dr. Klag: As someone who primarily treats patients who have developed a substance use disorder, it is difficult to see outside of that world and understand that some people may require long-term opioid medications to manage chronic pain. This study shows that this approach to pain management can be achieved safely with an involved interdisciplinary team. It also shows that, with the right knowledge and support, multimodal pain care is possible to minimize the use of opioid pain medications and decrease the risk of negative long-term consequences.

Did the results surprise you? Why, or why not?

The result that surprised me most was the lack of difference between the two treatment groups. This highlights that a comprehensive approach to pain treatment makes it possible to minimize opioid pain medications. This is a statistical representation of the importance of a multidisciplinary approach to pain management as well as opioid use and misuse.

Why was it important to do this study?

Treatment of chronic pain is incredibly challenging and frequently leaves providers feeling overwhelmed and deficient in their knowledge. While long-term opioid medication use is not the right choice for all patients with chronic pain, this study shows that, with the use of comprehensive and multimodal treatment in those for whom it is necessary, the potential long-term consequences can be minimized.

How may the findings potentially improve pain and reduce opioid use in patients on long-term opioid therapy?

Patients on long-term opioid therapy need more involved and comprehensive management. When that was provided, opioid medication doses decreased and pain improved, even among those who did not want their doses decreased. Improved pain control can decrease patients’ feelings of helplessness and need to seek additional opioids to manage their pain.

What else is important for clinicians to know about opioid treatment?

I would urge clinicians to understand that, while this study showed improvement in patient outcomes and the ability for patients to safely receive long-term opioid treatment, it does not mean that long-term opioid treatment is safe or advisable for the average patient. The treatment systems set in place in this study were intense and required multiple providers. Opioid use should still be partnered with an abundance of caution to maintain patients’ safety.