Economic Evaluation: A Randomized Pragmatic Trial of a Primary Care-based Cognitive Behavioral Intervention for Adults Receiving Long-term Opioids for Chronic Pain

• Published in: Medical care Vol. 60; no. 6; p. 423
• Main Authors: Smith, David H, O'Keeffe-Rosetti, Maureen, Leo, Michael C, Mayhew, Meghan, Benes, Lindsay, Bonifay, Allison, Deyo, Richard A, Elder, Charles R, Keefe, Francis J, McMullen, Carmit, Owen-Smith, Ashli, Trinacty, Connie M, Vollmer, William M, DeBar, Lynn
• Format: Journal Article
• Language: English
• Published: United States 01.06.2022
• Subjects: Adult; Analgesics, Opioid - therapeutic use; Chronic Pain - drug therapy; Cognition; Cognitive Behavioral Therapy; Cost-Benefit Analysis; Humans; Primary Health Care; Quality of Life; Quality-Adjusted Life Years
• ISSN: 1537-1948
• DOI: 10.1097/MLR.0000000000001713

Chronic pain is prevalent and costly; cost-effective nonpharmacological approaches that reduce pain and improve patient functioning are needed. Report the incremental cost-effectiveness ratio (ICER), compared with usual care, of cognitive behavioral therapy aimed at improving functioning and pain among patients with chronic pain on long-term opioid treatment. Economic evaluation conducted alongside a pragmatic cluster randomized trial. Adults with chronic pain on long-term opioid treatment (N=814). A cognitive behavioral therapy intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorists, nurses) with additional support from physical therapists, and pharmacists. Cost per quality adjusted life year (QALY) gained, and cost per additional responder (≥30% improvement on standard scale assessment of Pain, Enjoyment, General Activity, and Sleep). Costs were estimated as-delivered, and replication. Per patient intervention replication costs were $2145 ($2574 as-delivered). Those costs were completely offset by lower medical care costs; inclusive of the intervention, total medical care over follow-up was $1841 lower for intervention patients. Intervention group patients also had greater QALY and responder gains than did controls. Supplemental analyses using pain-related medical care costs revealed ICERs of $35,000, and $53,000 per QALY (for replication, and as-delivered intervention costs, respectively); the ICER when excluding patients with outlier follow-up costs was $106,000. Limited to 1-year follow-up; identification of pain-related utilization potentially incomplete. The intervention was the optimal choice at commonly accepted levels of willingness-to-pay for QALY gains; this finding was robust to sensitivity analyses.