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McGeary DD, Jaramillo C, Eapen B, et al. Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2022 Oct;103(10):1899-1907. doi: 10.1016/j.apmr.2022.06.012. Epub 2022 Aug 6. (Original study)
Abstract

OBJECTIVE: To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions.

DESIGN: Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up.

SETTING: Department of Veterans Affairs medical facility.

PARTICIPANTS: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions.

INTERVENTIONS: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility.

MAIN OUTCOME MEASURES: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect.

RESULTS: Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms).

CONCLUSION: These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

Ratings
Discipline Area Score
Psychologist 5 / 7
Physician 5 / 7
Rehab Clinician (OT/PT) 5 / 7
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Comments from MORE raters

Physician rater

Apparently, until now there were no evidence about the therapy applied in the study that appears to be useful in some patients.

Physician rater

Handling patients with polymorbid pain is complicated. Providing an interdisciplinary pain program may improve outcome, reduce pain, and possibly also reduce opioid needs.

Physician rater

Interesting but opioid use seems to remain the same in both groups.

Physician rater

Seems to be good short-term outcomes of interdisciplinary pain management in individuals with pain and comorbid psychiatric symptoms.

Physician rater

The authors state that this is the first RCT evidence of long-term (1 year) follow-up of a 3-week tailored outpatient multimodal interdisciplinary pain management program (IPMP) in US military veterans reporting persistent opioid use because of disabling service-related chronic musculoskeletal pain and TBI, PTSD, and/or depression/anxiety. Compared with usual care, IPMP demonstrated significant improvements in pain-related disability (primary outcome) but not in opioid reduction/discontinuation (secondary outcome). The reasons for the latter negative finding and limitations of this trial, including between-groups baseline differences and differential dropouts, are well discussed. Subjective evaluation of participants rated mindfulness as a valuable addition to the interdisciplinary treatment.

Physician rater

These trials are important and multidisciplinary pain management is well accepted. The challenge is available services.

Psychologist rater

The main concern with this study is the size of the research groups which contributes to a lack of generalizability. The design of the research and conclusions should prompt studies of replication.

Psychologist rater

This is a great addition to the research supporting multi-disciplinary programs. Unfortunately, the interventions with the TAU group are not specified very well, so that it is difficult to determine how much difference there was between the two groups. Nevertheless, it is a worthwhile read.

Psychologist rater

This is a promising study supporting interdisciplinary pain programs and specifically incorporating mindfulness. Given the study limitations, further study is recommended.

Rehab Clinician (OT/PT) rater

Although the population under study was "niche" and US based, the results are similar to what I am familiar with in studies investigating the same subject. The fall out rate of 20% is quite small. The results do not suggest a direct influence or bearing on my current practice and thinking. There is a comprehensive bibliography.

Rehab Clinician (OT/PT) rater

The study is limited by the utility of the primary outcome measure employed and publishing only baseline ODI data.
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