A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial.

Autor:	DeBar L; Kaiser Permanente Washington Health Research Institute, Seattle, Washington (L.D.)., Mayhew M; Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)., Benes L; Kaiser Permanente Center for Health Research, Portland, Oregon, and Montana State University College of Nursing, Missoula, Montana (L.B.)., Bonifay A; Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)., Deyo RA; Oregon Health & Science University School of Medicine, Portland, Oregon (R.A.D.)., Elder CR; Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)., Keefe FJ; Duke University School of Medicine, Durham, North Carolina (F.J.K.)., Leo MC; Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)., McMullen C; Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)., Owen-Smith A; Georgia State University School of Public Health and Kaiser Permanente Center for Clinical and Outcomes Research, Atlanta, Georgia (A.O.)., Smith DH; Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)., Trinacty CM; The Queen's Medical Center, Honolulu, Hawaii (C.M.T.)., Vollmer WM; Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.).
Jazyk:	angličtina
Zdroj:	Annals of internal medicine [Ann Intern Med] 2022 Jan; Vol. 175 (1), pp. 46-55. Date of Electronic Publication: 2021 Nov 02.
DOI:	10.7326/M21-1436
Abstrakt:	Background: Chronic pain is common, disabling, and costly. Few clinical trials have examined cognitive behavioral therapy (CBT) interventions embedded in primary care settings to improve chronic pain among those receiving long-term opioid therapy. Objective: To determine the effectiveness of a group-based CBT intervention for chronic pain. Design: Pragmatic, cluster randomized controlled trial. (ClinicalTrials.gov: NCT02113592). Setting: Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest. Participants: Adults (aged ≥18 years) with mixed chronic pain conditions receiving long-term opioid therapy. Intervention: A CBT intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorist, nurse, physical therapist, and pharmacist) versus usual care. Measurements: Self-reported pain impact (primary outcome, as measured by the PEGS scale [pain intensity and interference with enjoyment of life, general activity, and sleep]) was assessed quarterly over 12 months. Pain-related disability, satisfaction with care, and opioid and benzodiazepine use based on electronic health care data were secondary outcomes. Results: A total of 850 patients participated, representing 106 clusters of primary care providers (mean age, 60.3 years; 67.4% women); 816 (96.0%) completed follow-up assessments. Intervention patients sustained larger reductions on all self-reported outcomes from baseline to 12-month follow-up; the change in PEGS score was -0.434 point (95% CI, -0.690 to -0.178 point) for pain impact, and the change in pain-related disability was -0.060 point (CI, -0.084 to -0.035 point). At 6 months, intervention patients reported higher satisfaction with primary care (difference, 0.230 point [CI, 0.053 to 0.406 point]) and pain services (difference, 0.336 point [CI, 0.129 to 0.543 point]). Benzodiazepine use decreased more in the intervention group (absolute risk difference, -0.055 [CI, -0.099 to -0.011]), but opioid use did not differ significantly between groups. Limitation: The inclusion of only patients with insurance in large integrated health care systems limited generalizability, and the clinical effect of change in scores is unclear. Conclusion: Primary care-based CBT, using frontline clinicians, produced modest but sustained reductions in measures of pain and pain-related disability compared with usual care but did not reduce use of opioid medication. Primary Funding Source: National Institutes of Health.
Databáze:	MEDLINE
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