Therapeutic Interactive Voice Response (TIVR) to reduce analgesic medication use for chronic pain management

Abstract

This paper examines whether a telephone-based, automated maintenance enhancement program can help to reduce opioid and nonsteroidal anti-inflamatory drugs (NSAID) analgesic use in patients with chronic pain. Following 11 weeks of group cognitive-behavioral therapy (CBT), 51 subjects with chronic musculoskeletal pain were randomized to 1 of 2 study groups. Twenty-six subjects participated in 4 months of a Therapeutic Interactive Voice Response (TIVR) program in addition to standard follow-up care, while a control group of 25 subjects received standard follow-up care only. TIVR is an automated, telephone-based tool developed for the maintenance and enhancement of CBT skills. Opioid analgesic use decreased in the experimental group in both follow-ups: 4 and 8 months postCBT. In addition, at 8-month follow-up, 21% of the TIVR subjects had discontinued the use of opioid analgesics, 23% had discontinued NSAIDS, and 10% had discontinued antidepressant medications. In contrast, the control group showed increases in opioid and NSAIDS use. Analysis of covariance (ANCOVA) revealed significant between-group differences in opioid analgesic use at 8-month follow up (P = .004). We have previously demonstrated the efficacy of TIVR to decrease pain and improve coping; this analysis demonstrates that the use of TIVR may also result in concurrent reductions in opioid analgesic and NSAID medications use.

Perspective: This article demonstrates that the Therapeutic Interactive Voice Response maintenance enhancement program can help to reduce opioid analgesic use in patients with chronic pain. This automated maintenance enhancement program could potentially assist patients not only to decrease pain and improve coping, but also to diminish the likelihood of opioid dependence.

Figure 1

This CONSORT flow diagram details study recruitment (numbers 1–5), randomization and group allocation (number 6), follow-up (numbers 7–8) and analysis.

Figure 2

A Model of Relapse Prevention Process in Coping with Pain. The central core of Figure 2 depicts a typical relapse cascade with the boxes in the periphery representing the particular TIVR Components and the coping skills promoted to intervene in the relapse cascade. (Modified after F. Keefe by M. Naylor)

Figure 3

Figure 3 depicts the changes in medications dose used while retaining for analysis all subjects who used the medication at least once. A) opioids – equivalent of mg morphine sulfate, B) NSAIDS – equivalent of mg aspirin, C) benzodiazepines - equivalent of mg diazepam, D) antidepressants - equivalent of mg fluoxetine. There was one outlier in control group in opioids at the 8th month follow-up. Note: black bars represent TIVR group white bars represent Control group dotted line (----) represents statistically significant dose increase solid line (—) represents statistically significant dose decrease