A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial.
A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial.
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DOI：
10.7326/m21-1436
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发表时间：
2022-01
影响因子：
39.2
通讯作者：
Vollmer WM
中科院分区：
文献类型：
--
作者：
DeBar L;Mayhew M;Benes L;Bonifay A;Deyo RA;Elder CR;Keefe FJ;Leo MC;McMullen C;Owen-Smith A;Smith DH;Trinacty CM;Vollmer WM
慢性疼痛是常见的，致残的，昂贵的。很少有临床试验检查初级保健机构中嵌入的认知行为疗法（CBT）干预措施，以改善接受长期阿片类药物治疗的患者的慢性疼痛。确定基于群体的CBT干预慢性疼痛的有效性。实用，集群随机对照试验。（ClinicalTrials.gov: NCT02113592） Kaiser Permanente医疗保健系统在乔治亚州、夏威夷和西北部。接受长期阿片类药物治疗的混合慢性疼痛的成人（年龄≥18岁）。一个跨学科团队（行为学家、护士、物理治疗师和药剂师）以每周12次、每次90分钟的小组方式教授疼痛自我管理技能的CBT干预，而不是常规护理。自我报告的疼痛影响（主要结果，通过PEGS量表[疼痛强度和对生活享受、一般活动和睡眠的干扰]测量）在12个月内每季度评估一次。疼痛相关残疾、护理满意度以及基于电子医疗保健数据的阿片类药物和苯二氮卓类药物使用是次要结局。共有850名患者参与，代表106组初级保健提供者（平均年龄60.3岁，67.4%为女性）；816例（96.0%）完成随访评估。从基线到12个月的随访，干预患者的所有自我报告结果均有较大的下降；疼痛影响的PEGS评分变化为- 0.434分（95% CI, - 0.690至- 0.178分），疼痛相关残疾的变化为- 0.060分（CI, - 0.084至- 0.035分）。6个月时，干预患者对初级保健（差异0.230点[CI， 0.053 ~ 0.406点]）和疼痛服务（差异0.336点[CI， 0.129 ~ 0.543点]）的满意度较高。干预组苯二氮卓类药物的使用减少更多（绝对风险差异为- 0.055 [CI, - 0.099至- 0.011]），但阿片类药物的使用在组间无显著差异。在大型综合医疗保健系统中仅纳入有保险的患者限制了通用性，并且评分变化的临床效果尚不清楚。与常规护理相比，使用一线临床医生进行的基于初级保健的CBT在疼痛和疼痛相关残疾方面产生了适度但持续的减少，但没有减少阿片类药物的使用。国立卫生研究院。
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. To determine the effectiveness of a group-based CBT intervention for chronic pain. Pragmatic, cluster randomized controlled trial. (ClinicalTrials.gov: NCT02113592) Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest. Adults (aged ≥18 years) with mixed chronic pain conditions receiving long-term opioid therapy. 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. 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. 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. 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. 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. National Institutes of Health.