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2019 HSR&D/QUERI National Conference Abstract

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1147 — Improving Chronic Pain Care and Opioid Safety in VA Primary Care: Implementation and Evaluation of the Integrated Pain Team Model

Lead/Presenter: Karen Seal,  SFVAHCS
All Authors: Seal KH (San Francisco VA Healthcare System and University of California, San Francisco), Rife,T (San Francisco VA Healthcare System), Li,Y (San Francisco VA Healthcare System) Tighe,J (San Francisco VA Healthcare System)

Objectives:
National guidelines advise clinicians to decrease the use of opioids for chronic pain treatment, yet we are lacking evidence for interventions to de-implement opioids. The Integrated Pain Team (IPT) consists of a medical provider, psychologist and pharmacist who together provide short-term management of Veterans with chronic pain with opioid-related concerns. We evaluated the effectiveness of the (IPT) model to decrease opioid use and improve opioid safety.

Methods:
New IPT patients (N = 147) were matched to similar Veterans with chronic pain prescribed opioids receiving usual Primary Care (UPC, N = 147) on visit date, age, gender, number and type of psychiatric diagnoses and baseline daily opioid dose (as morphine equivalent daily dose, MEDD). Veterans were assessed prospectively from baseline to 3- and 6-months for change in opioid dose and opioid safety outcomes.

Results:
Among all 294 Veterans, mean age was 63 years (SD = 12 years); 90% male; 65% white; 36% had received depression diagnoses, 27% PTSD; 18% anxiety and average baseline MEDD was 124.3 mg. Veterans with chronic pain followed by IPT vs. UPC had a mean MEDD decrease of 56 milligrams (mg) vs. 18 mg after 6 months (p = 0.03). An adjusted mixed-effects linear regression showed significant average treatment effects of the IPT and time interaction. At 3 months, the reduction of MEDD in the IPT group was 33.6 mg (95% CI: 12.2-55.0 mg) greater than UPC (p = 0.002), and at 6 months, reduction of opioid dose in the IPT group was 38.2 mg (95% CI: 13.0-63.5 mg) greater than UPC (p = 0.003). This was independent of race, baseline pain severity, opioid use disorder, co-prescription of opioids and benzodiazepines and number of emergency department visits. There were also significant improvements in opioid safety outcomes: urine drug screen monitoring and naloxone kit distribution at 6 months (all p-values < 0.001).

Implications:
Interdisciplinary models of pain care can lead to sustained reductions in opioid dose and improved opioid safety outcomes in Veterans with chronic pain in VA primary care.

Impacts:
The IPT model is now being disseminated and implemented in the context of a large-scale pragmatic trial to determine its effectiveness to improve pain and decrease opioid use among large numbers of Veterans with high-risk opioid use.