Collaborative Care Management for Community-Dwelling Older Adults Prescribed Opioids: A Summary of Pilot Program Findings

Abstract

<h3>Introduction</h3> Pain is highly comorbid with mental health problems, and can lead to significant disability and loss of function. Pain is common among older adults, with approximately half of older adults nationwide reporting experiencing bothersome pain in the preceding month. The treatment of pain in later life is complicated by a variety of factors, and there are significant safety risks associated with the use of analgesics, especially opioids. Multimodal strategies and collaborative care models that employ both non-pharmacological and pharmacological methods of pain care management may be especially promising in treating pain and improving outcomes. The objective of this project was to explore preliminary results from a pilot study of a telephone-delivered collaborative care service designed for community-dwelling older adults with chronic pain receiving prescriptions for high doses of opioids. Specifically, we were interested in examining program feasibility and acceptability, the extent to which engaged patients and their prescribers achieved opioid dose reduction, and changes in patient-level symptoms (e.g., pain severity and interference, depressive symptoms). <h3>Methods</h3> Eligible participants included 82 older adults referred by the Pennsylvania Department of Aging's pharmaceutical assistance program for low-income seniors (PACE/PACENET) to the University of Pennsylvania/PACE Behavioral Health Laboratory program. Referred patients were identified as receiving chronic opioid prescriptions for > 120 mg morphine-equivalent dose (MED) per day. Upon enrollment, patients first completed a comprehensive baseline clinical assessment. Clinical data on mental health, cognition, pain and functional status, as well as self-reported daily opioid dose and biopsychosocial needs, were collected over the phone and entered into the program's informatics tool. Patients next engaged in a series of telephone sessions during which care managers offered individualized treatment planning. Program goals included opioid dose reduction to safer levels and improved pain and psychosocial outcomes. Treatment modalities offered included: (1) behavioral pain management, (2) general medication education, (3) reinforcing positive health behaviors, (4) addressing barriers to change, (5) scheduling positive activities, and (6) relaxation techniques. Following each session, summary reports were sent to prescribers with recommendations for pain care management and opioid dose reduction. <h3>Results</h3> Enrolled patients were on average 73.5 (+/-6.1) years old, and the majority were non-Hispanic white (91%) and female (70%). Seventy-seven percent of the sample met criteria for clinically significant anxiety or depressive symptomatology. Of the 82 patients completing the baseline assessment, 53 (65%) engaged in the program. Patients were considered engaged in the program if they completed the baseline assessment and two or more additional follow-up contacts with a care manager. Those who engaged in the program did not differ on sociodemographic or clinical characteristics or baseline reports of pain when compared to those who did not engage. Pre-post intervention comparisons suggest a significant reduction in medication dose at the last contact relative to baseline. Further, at their last clinical contact, 66% of engaged patients achieved dose reductions of >20%. While there were no significant changes in pain interference or pain-related self-efficacy, engaged patients did report reductions in pain severity (p=0.05) and depressive symptoms (p=0.003) at the last contact relative to baseline. Preliminary findings also suggest that patients who achieved dose reductions of >20%, compared to those who did not, showed greater reductions in depressive symptoms and pain interference at the last contact relative to baseline. Pharmacy record data comparing those who engaged versus those who did not engage in the program were also collected for analysis. <h3>Conclusions</h3> In conclusion, the findings provide preliminary support for the feasibility of a community-based, collaborative care model for pain management and suggest the potential for positive treatment outcomes. The results also support further development and evaluation of collaborative care models that aim to address opioid use in later life. <h3>Funding</h3> Pennsylvania Department of Aging, PACE/PACENET program