Effects of pain and prescription opioid use on outcomes in a collaborative care intervention for anxiety

Abstract

Objective: To determine the effects of pain and opioid pain medication use on clinical and functional outcomes in 1004 primary care patients with an anxiety disorder randomized to receive the Coordinated Anxiety Learning and Management (CALM) collaborative care intervention (cognitive-behavioral therapy and/or medication) versus usual care.

Methods: A total of 1004 patients with panic disorder, generalized anxiety disorder, social anxiety disorder, or posttraumatic stress disorder were randomized to CALM or usual care. Outcomes at 6, 12, and 18 months were compared in patients with and without moderate pain interference (for the entire anxiety disorder group and then just those with comorbid major depression) and in patients taking and not taking opioid medication (entire group, just those with comorbid major depression, and just those with moderate pain interference).

Results: Patients with pain interference and patients taking opioid pain medication were more anxious [Brief Symptom Inventory anxiety subscale] and disabled (Sheehan Disability) at baseline, improved over time at similar rates, but at 18 months had lower response and remission rates. There was no moderating effect on the intervention. In patients with comorbid major depression, patients using opioid medications showed a trend for less disability improvement over time, and in patients with pain, patients using opioids showed less sustained anxiety response at 18 months.

Conclusions: Anxious patients with pain benefit as much as those without pain from cognitive-behavioral therapy and medication treatment. Among patients with pain, however, there is some evidence of a reduced anxiety treatment response in those taking opioid medication, which should be further studied.

Trial registration: ClinicalTrials.gov NCT00347269.

Conflict of interest statement

Potential Conflicts of Interest: Dr. Roy-Byrne reports income from editorial work on the evidence-based physician resource, UpToDate, on the journal Depression and Anxiety, and on Journal Watch Psychiatry, and stock options from his consulting work with the electronic medical record company, Valant Medical Solutions. Dr. Sullivan reports receiving grants from Pfizer and Covidien, and having served on a Janssen advisory board. Dr. Craske reports receiving royalties from Oxford University Press and APA Books. Dr. Stein reports income from editorial work on the evidence-based physician resource, UpToDate, and on the journal Depression and Anxiety. For the remaining authors none were declared.

Figures

FIGURE 1

BSI-12 scores over time for those with and without moderate pain at baseline. BSI-12 indicates Brief Symptom Inventory 12-item anxiety subscale.

FIGURE 2

BSI-12 scores over time for those with and without baseline use of opioids. BSI-12 indicates Brief Symptom Inventory 12-item anxiety subscale.

FIGURE 3

Sheehan Disability scores over time for depressed patients, with and without baseline use of opioids.

FIGURE 4

BSI-12 scores over time in patients with moderate pain at baseline, with and without baseline use of opioids. BSI-12 indicates Brief Symptom Inventory 12-item anxiety subscale; CALM, Coordinated Anxiety Learning and Management group; UC, usual care group.