Literature Collection

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.

BACKGROUND: Opioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs. METHODS: Residents of Rhode Island aged 18-65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses. DISCUSSION: If the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose. TRIAL REGISTRATION: ClinicalTrials.gov NCT04372238 . Registered on 01 May 2020.

BACKGROUND: Collaborative models for depression have not been widely adopted throughout the USA, possibly because there are no successful roadmaps for implementing these types of models. OBJECTIVE: To provide such a roadmap through a case study of the institutionalization of a depression care management (DCM) initiative for adult depression in a large healthcare system serving over 300,000 adults with depression. DESIGN: A retrospective observational program evaluation. Program evaluation results are presented for those patients enrolled in the initiative from January 1, 2015, to December 31, 2018. PARTICIPANTS: Over a 4-year period, 17,052 patients were treated in the DCM program. In general, participants were women (76%), were Hispanic (47%), spoke English (84%), and were 51.1 ± 18.3 years old, the majority of whom were 30-64 years old (57%). INTERVENTION: The collaborative care portion of the DCM initiative (DCM program) was implemented by a collaborative care team containing a treatment specialist, an assessment specialist, administrative staff, a primary care physician, and a psychiatry physician. MAIN MEASURES: The main outcome measures were total score on the 9-item Patient Health Questionnaire (PHQ-9). Outcomes were improvement (defined as at least 50% reduction in symptoms) and remission (defined as a PHQ-9 less than 5) of depression symptoms. Follow-up of depression symptoms was also collected at 6 months following discharge. KEY RESULTS: The average course of treatment in 2018, after full implementation, was 4.6 ± 3.0 months; 62% of patients experienced improvement in symptoms, and 45% experienced remission of their depression at the time of discharge. These rates were maintained at the 6-month follow-up. CONCLUSIONS: Collaborative care for depression can be institutionalized in large healthcare systems and be sustained with a specific, detailed roadmap that includes workflows, training, treatment guidelines, and clear documentation standards that are linked to performance metrics. Extensive stakeholder engagement at every level is also critical for success.