A Pain and Coordination Plan for Reduced Opioid Use After Accidental Injuries (PAC-plan)

A Pain and Coordination Plan (PAC-plan) in Transition Between Hospital and Primary Care to Reduce Opioid Use in Patients After Accidental Injuries: A Randomized Controlled Trial

This clinical trial aims to lower the number of people who use opioids and improve the quality of health in patients who have experienced accidental injury by implementing a Pain and Coordination Plan (PAC-plan). The PAC-plan will be given upon discharge from the hospital.

The main questions this study aims to answer are:

• Can the PAC-plan reduce opioid use in patients after accidental injuries?
• Can the PAC-plan increase quality of life in patients after accidental injuries?
• Is implementation of the PAC-plan after accidental injuries cost-effective?

Participants will be randomly assigned to the PAC-plan or usual care. The PAC-plan includes:

• an opioid management plan upon discharge from the hospital
• an appointment with his/her general practitioner within 2-4 weeks after discharge
• the general practitioner will be given the opportunity for increased collaboration with the hospital specialists

Participants in both groups will be asked to answer questionnaires about their health at discharge, and at 6 and 52 weeks after discharge from the hospital. In addition, the researchers will use data from the Norwegian Prescription Database to measure use of opioids and other relevant drugs, the Norwegian Patient Registry (NPR) and the Norwegian Registry for Primary Health Care (KPR) for the use of health care services and Statistics Norway for data on sick leave and other social security benefits.

Study Overview

• Status: Active, not recruiting
• Conditions: Pain, Postoperative; Opioid Use; Injury Traumatic
• Intervention / Treatment: Other: PAC-plan

Detailed Description

Introduction: Patients experiencing serious injuries are at risk of developing long-term opioid use, yet many don't receive plans for opioid reduction when discharged from the hospital. General Practitioners (GPs) also experience insufficient communication from the hospital on pain management plans. Opioids are often essential for managing acute pain in patients following serious injuries. However, it is crucial to prioritize safe and appropriate pain management in subsequent phases. The opioid epidemic in the USA, characterized by opioid use disorders and addiction, has resulted in high mortality rates and a public health crisis. In 2017, opioid dependence outside the USA was estimated to account for over 1% of age-standardized years lived with disability in 135 countries. Considering the devastating impact of the opioid epidemic in the USA, it is imperative to draw lessons from these experiences and implement preventive measures to avoid a similar crisis in other countries.

Aim: This study aims to explore if a Pain and Coordination Plan (PAC-plan) for patients after accidental injury can reduce opioid use and improve quality of life, and if the intervention is cost-effective.

Methods: The study is designed as a prospective randomized controlled trial (RCT) to evaluate the effect of a PAC-plan. The PAC-plan consists of three main elements: an opioid management plan upon discharge from the hospital, an appointment with the participant's regular GP within 2-4 weeks after discharge and an opportunity for increased collaboration between GP and hospital specialists.

Patients will be recruited from the Division of orthopaedic surgery, Oslo University Hospital (OUH), Norway. OUH is a highly specialized hospital in charge of extensive regional and local hospital assignments in the South-Eastern Health region in Norway and is described as a level 1 trauma centre. The primary outcome is oral morphine equivalent (OMEQ) consumption 6 weeks after discharge. Secondary outcome measures are OMEQ 52 weeks after discharge. In addition, registry-based OMEQ and other addictive drugs, pain, health-related quality of life (HRQoL) and other Patient-reported outcome measures (PROMs) at 6 and 52 weeks, and finally use of health care services and sick leave. The registry-based OMEQ will be collected from the Norwegian Prescription Database (NorPD). Data will also be collected from the the Norwegian Patient Registry (NPR), the Norwegian Patient Registry (NPR), the Norwegian Registry for Primary Health Care (KPR) and Statistics Norway.

• Study Type: Interventional
• Enrollment (Actual): 271
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Norway
  • Oslo, Norway, 0424
    • Oslo University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Adults ≥18 years of age who have undergone acute orthopaedic surgery following accidental injury
• Discharged on opioid medication

Exclusion Criteria:

• Unable to read, speak, and write Norwegian
• Severe cognitive impairment/inability to consent
• Not discharged to home
• Currently in cancer treatment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: PAC-plan; The patients receive a Pain- and Coordination plan (PAC-plan) at discharge from the hospital. The PAC-plan includes: Upon discharge, patients have a patient-centered conversation and receive written information covering patient education on opioids, a tapering plan, and a plan for contact and follow-up with the general practitioner. The information is based on the Norwegian National Guide for Addictive Medications.; Before discharge, patients are scheduled an appointment with the GP, preferably within the first 2 weeks (2-4 weeks), for a follow-up regarding the injury and pain management.; The GP is invited to maintain contact with the study nurse at the hospital for one year. The general practitioner can call for consultation with the study nurse, and if necessary, be connected with relevant medical specialists for advice and eventually further follow-up.	Other: PAC-plan; The participants will be asked to complete electronic questionnaires at baseline, and at 6 weeks and 52 weeks after discharge from the hospital. The completion of these questionnaires will take place during the 6-week follow-up appointment at the hospital (a standard follow-up for all patients undergoing surgery at the Division of Orthopedic Surgery, Oslo University Hospital, Norway). Additionally, participants will be invited for a phone-based follow-up appointment with the study coordinator 52 weeks after discharge. The participants will receive the questionnaires electronically via SMS or email. If electronic options are not feasible, data can be collected through paper questionnaires sent by mail. Data will not be directly obtained from general practitioners.
No Intervention: Control; Treatment and follow-up as usual.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Opioid use	Opioid use last 24 hours measured in oral morphine equivalents (OMEQ), self-reported	6 weeks post-discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Opioid use	Opioid use last 24 hours measured in oral morphine equivalents (OMEQ), self-reported	52 weeks post-discharge
Opioid use measured in oral morphine equivalents (OMEQ), registry-based	The Norwegian Prescription Database, NorPD	6 weeks post-discharge
Opioid use measured in oral morphine equivalents (OMEQ), registry-based	The Norwegian Prescription Database, NorPD	52 weeks post-discharge
Numeric Rating Scale for pain intensity scores	Pain intensity, self-reported by Numeric Rating Scale (NRS-11). Scale from 0 to 10, with 0 being "no pain" and 10 being "the worst pain imaginable."	6 weeks post-discharge
Numeric Rating Scale for pain intensity scores	Pain intensity, self-reported by Numeric Rating Scale (NRS-11). Scale from 0 to 10, with 0 being "no pain" and 10 being "the worst pain imaginable."	52 weeks post-discharge
Norwegian Injustice Experience Questionnaire (IEQ-N)	Perceived injustice measured with the Injustice Experience Questionnaire (IEQ). The IEQ is a self-report 12-item questionnaire and each item is scored on a five-point scale from zero ("never") to four ("all the time"). The total score on the IEQ ranges from 0 to 48, with higher scores indicating higher levels of perceived injustice	6 weeks post-discharge
Norwegian Injustice Experience Questionnaire (IEQ-N)	Perceived injustice measured with the Injustice Experience Questionnaire (IEQ). The IEQ is a self-report 12-item questionnaire and each item is scored on a five-point scale from zero ("never") to four ("all the time"). The total score on the IEQ ranges from 0 to 48, with higher scores indicating higher levels of perceived injustice	52 weeks post-discharge
Life Orientation Test Revised (LOT-R)	Optimism measured with the Life Orientation Test Revised (LOT-R). The measure consists of 10 items, and participants indicate their level of agreement with each item on a 5-point scale ranging from 0 (strongly disagree) to 4 (strongly agree). The scores on this scale can range from 0 to 24, with higher scores indicating greater levels of optimism and lower scores indicating lower levels of optimism.	6 weeks post-discharge
Life Orientation Test Revised (LOT-R)	Optimism measured with the Life Orientation Test Revised (LOT-R). The measure consists of 10 items, and participants indicate their level of agreement with each item on a 5-point scale ranging from 0 (strongly disagree) to 4 (strongly agree). The scores on this scale can range from 0 to 24, with higher scores indicating greater levels of optimism and lower scores indicating lower levels of optimism.	52 weeks post-discharge
Patient Health Questionnaire-9	Depression symptoms and severity measured by the Patient Health Questionnaire-9 (PHQ-9).The PHQ-9 consists of nine items and the participants rate the frequency of each symptom on a Likert scale ranging from 0 (not at all) to 3 (nearly every day). The scores can range from 0-27. In addition to a total score, categories are defined to indicate severity of depression symptoms. These categories are defined as follows: none (total score from 0 to 4), mild (total score from 5 to 9), moderate (total score from 10 to 14), moderately severe (total score from 15 to 19), and severe (total score from 20 to 27).	6 weeks post-discharge
Patient Health Questionnaire-9	Depression symptoms and severity measured by the Patient Health Questionnaire-9 (PHQ-9).The PHQ-9 consists of nine items and the participants rate the frequency of each symptom on a Likert scale ranging from 0 (not at all) to 3 (nearly every day). The scores can range from 0-27. In addition to a total score, categories are defined to indicate severity of depression symptoms. These categories are defined as follows: none (total score from 0 to 4), mild (total score from 5 to 9), moderate (total score from 10 to 14), moderately severe (total score from 15 to 19), and severe (total score from 20 to 27).	52 weeks post-discharge
EQ-5D-5L (EuroQol, 5 dimensions, 5 levels) for health-related quality of life	Health-related quality of life measured with the EQ-5D-5L. The EQ-5D-5L consists of two parts: the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS). The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The EQ visual analogue scale (EQ VAS) records the patient's self-rated health on a VAS ranging from 0 to 100, with higher scores indicating better self-reported health.	6 weeks post-discharge
EQ-5D-5L (EuroQol, 5 dimensions, 5 levels) for health-related quality of life	Health-related quality of life measured with the EQ-5D-5L. The EQ-5D-5L consists of two parts: the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS). The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The EQ visual analogue scale (EQ VAS) records the patient's self-rated health on a VAS ranging from 0 to 100, with higher scores indicating better self-reported health.	52 weeks post-discharge
HUNT (the Nord-Trøndelag health study) physical activity questionnaire (HUNT 1 PA-Q)	The HUNT 1 PA-Q consists of three sets of questions addressing the average number of times exercising each week, the average intensity and average hours each time. Each set of questions has five, three, or four response choices, respectively. The HUNT 1 PA-Q measures physical exercise as the product of average frequency (0.0-5.0 points), duration (0.10-1.00 points) and intensity (1-3 points) each week, giving an index ranging from 0.00 to 15.00, with 15.00 as the best score	6 weeks post-discharge
HUNT (the Nord-Trøndelag health study) physical activity questionnaire (HUNT1 PA-Q)	The HUNT 1 PA-Q consists of three sets of questions addressing the average number of times exercising each week, the average intensity and average hours each time. Each set of questions has five, three, or four response choices, respectively. The HUNT 1 PA-Q measures physical exercise as the product of average frequency (0.0-5.0 points), duration (0.10-1.00 points) and intensity (1-3 points) each week, giving an index ranging from 0.00 to 15.00, with 15.00 as the best score.	52 weeks post-discharge
Insomnia Severity Index (ISI) last 2 weeks	Perceived insomnia severity measured by the Insomnia Severity Index (ISI). The ISI consists of seven items and the participants rate each item on a scale from 0 to 4, from less to more severe. The total score is the sum of each individual item and can range from 0 to 28 (28 = most severe insomnia).	6 weeks post-discharge
Insomnia Severity Index (ISI) last 2 weeks	Perceived insomnia severity measured by the Insomnia Severity Index (ISI). The ISI consists of seven items and the participants rate each item on a scale from 0 to 4, from less to more severe. The total score is the sum of each individual item and can range from 0 to 28 (28 = most severe insomnia).	52 weeks post-discharge
Cost-effectiveness	The cost-effectiveness of the intervention will be assessed by the incremental cost-effectiveness ratio (ICER), defined by the incremental costs (the difference in costs between the intervention group and the control group) per quality-adjusted life year (QALY) gained. In the health economic analysis, we will also present differences in costs associated with healthcare service consumption (based on data from the Norwegian Prescription Database (NorPD), the Norwegian Patient Registry (NPR), and the Norwegian Registry for Primary Health Care (KPR), as well as differences in sick leave and disability benefits (using data from Statistics Norway).	52 weeks post-discharge
Use of addictive and psychoactive drugs, registry-based	Prescribed addictive medication (other than opioids) and psychoactive drugs (antidepressants and antipsychotics). Obtained from the Norwegian Prescription Database, NorPD.	6 weeks post-discharge
Use of addictive and psychoactive drugs, registry-based	Prescribed addictive medication (other than opioids) and psychoactive drugs (antidepressants and antipsychotics). Obtained from the Norwegian Prescription Database, NorPD.	52 weeks post-discharge

Collaborators and Investigators

• Sponsor: University of Oslo
• Collaborators: Oslo University Hospital; The Norwegian Research Fund for General Practice
• Investigators: Study Director: Lene B Solberg, PhD MD, Oslo University Hospital; Principal Investigator: Trygve Skonnord, PhD MD, Department of General Practice, Institute of Health and Society, University of Oslo, Norway

Publications and helpful links

Helpful Links

• Website for the PAC-plan project at the University of Oslo

Study record dates

Study Major Dates

• Study Start (Actual): September 25, 2023
• Primary Completion (Actual): April 30, 2026
• Study Completion (Estimated): December 1, 2028

Study Registration Dates

• First Submitted: September 19, 2023
• First Submitted That Met QC Criteria: September 25, 2023
• First Posted (Actual): September 26, 2023

Study Record Updates

• Last Update Posted (Actual): May 8, 2026
• Last Update Submitted That Met QC Criteria: May 4, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: Pain; Pain management; Injuries; Opioids; Collaboration
• Additional Relevant MeSH Terms: Neurologic Manifestations; Nervous System Diseases; Postoperative Complications; Pathologic Processes; Neurobehavioral Manifestations; Perceptual Disorders; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Pain; Pain, Postoperative; Wounds and Injuries; Agnosia
• Other Study ID Numbers: 487948 (REK)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: It is not yet known if there will be a plan to make individual patient data (IPD) available.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No