The study, led by Benjamin J. Morasco of the VA Portland Health Care System and Oregon Health & Science University, drew its data from the Veterans’ Pain Care Organizational Improvement Comparative Effectiveness study, known as VOICE. That parent trial was a multisite, twelve-month randomized comparative effectiveness trial designed to test two real-world implementations of collaborative care for chronic pain, a model in which primary care teams work with specialized consultants to manage patients’ conditions systematically rather than leaving each clinician to improvise. Participants were randomized to one of two interventions that differed in resource intensity: an intensive interdisciplinary pain team, or a less resource-intensive pharmacist-led collaborative management approach. Both arms were grounded in the same collaborative care architecture, and both were delivered within the routine operations of the Veterans Health Administration, which is precisely what makes the trial pragmatic rather than a test of an idealized clinic that exists only in research settings.

For the secondary analysis, the research team collapsed the two treatment conditions and asked a different question than the original trial: did baseline substance use disorder status predict how patients fared? The answer required first establishing who carried that status. Of the 778 participants enrolled, 250, or 32.1 percent, met criteria for potential substance use disorder at baseline. That figure is striking in its own right, and it aligns with a broader literature documenting that roughly one in three patients on long-term opioid therapy for chronic pain has co-occurring substance use disorder. Epidemiological studies across health systems, including analyses of Norwegian health registries and large electronic health record datasets, have repeatedly found elevated rates of substance use diagnoses among chronic pain patients prescribed opioids, making this population impossible to ignore in any serious effort to improve opioid prescribing.

The demographic and clinical profile of the two groups differed in ways that matter for interpretation. Participants with potential substance use disorder were younger and more likely to have co-occurring mental health diagnoses than participants without it. Yet, critically, the groups showed no differences at baseline in pain interference, pain intensity, or prescription opioid dose. This baseline equivalence is methodologically important: it means that any divergence in outcomes during the trial could plausibly be attributed to substance use disorder status rather than to the groups starting from different levels of pain or different opioid exposures. The researchers measured pain using validated instruments, including the Brief Pain Inventory, which captures both the intensity of pain and the degree to which it interferes with daily functioning, a distinction that has become central to modern pain outcome assessment because interference often responds to treatment even when raw intensity does not fully remit.

The twelve-month results were unambiguous. Participants in both the potential substance use disorder group and the no-disorder group achieved statistically significant reductions in pain interference and pain intensity, alongside reductions in prescription opioid dose. In adjusted analyses that accounted for the demographic and clinical differences between groups, there was no difference between the groups in the magnitude of change on any of these outcomes. In other words, substance use disorder status did not blunt the response to collaborative care, did not prevent opioid dose reduction, and did not leave patients with more residual pain than their peers. For a population often excluded from trials or treated as a special case requiring separate pathways, this is a consequential null finding, in the best sense of the term.

The technical significance of this result becomes clearer when set against the prior evidence base. Earlier randomized trials had tested psychosocial pain interventions specifically tailored to patients in substance use disorder treatment, including work by Ilgen and colleagues and mindfulness-oriented recovery enhancement trials by Garland and colleagues, which showed that dedicated programs could help. But those studies evaluated interventions designed for the substance-using population, leaving open whether mainstream collaborative pain care, the kind most health systems could actually deploy, would work as well for these patients. A prior observational study by Morasco and colleagues had examined pain-related function over twelve months in primary care patients with musculoskeletal pain and found associations worth probing further. The new analysis closes that gap by embedding the substance use disorder question directly inside a rigorous randomized trial of standard collaborative care models, giving the finding a level of causal confidence that observational data cannot provide.

The opioid dose reduction component of the study carries particular weight given the national conversation about tapering. Systematic reviews, including one by Frank and colleagues, have documented that dose reduction and discontinuation of long-term opioid therapy can produce mixed patient outcomes, and observational studies from multiple health systems have linked rapid or forced tapering to overdose, mental health crisis, and other adverse events. The VOICE trial’s collaborative care approach, by contrast, paired dose reduction with active pain treatment, and the new analysis shows that patients with potential substance use disorder achieved dose reductions without differential harm to their pain outcomes. This suggests that the safest tapering is not simply a matter of lowering doses but of lowering them within a supportive treatment structure, and that patients with substance use disorder should not be steered away from such structures on the assumption that they will fail.

Several design features strengthen the study’s real-world relevance. The pragmatic trial design meant that interventions were delivered in ordinary VA primary care settings rather than in specialized research clinics, and the enrollment of 778 patients across multiple sites provided the statistical power to detect meaningful differences if they existed. The identification of potential substance use disorder relied on validated screening approaches, including instruments such as the AUDIT-C for alcohol and the TAPS tool for unhealthy substance use, supplemented by diagnostic codes whose validity in administrative data has been verified through chart review in prior work. The trial was registered at ClinicalTrials.gov as NCT03026790, funded by the Patient-Centered Outcomes Research Institute, and supported by the Department of Veterans Affairs, with the funder having no role in the design, analysis, or decision to publish.

The study’s limitations deserve honest acknowledgment. The population consisted of veterans, most of whom receive integrated care within a single health system, so generalization to civilian populations with fragmented insurance and care remains an empirical question. The substance use disorder classification was based on screening and potential criteria rather than structured clinical interviews, and the analysis examined outcomes at twelve months rather than over longer horizons. The parent trial compared two collaborative care variants and collapsed them for this analysis, so the results speak to collaborative care as a class rather than distinguishing which model works better for which subgroup. Nonetheless, the consistency of the findings across pain interference, pain intensity, and opioid dose outcomes lends credibility to the central conclusion.

The clinical implications are straightforward and potentially practice-changing. Roughly a third of patients on long-term opioid therapy carry a substance use disorder diagnosis, and clinicians have long faced a dilemma: treat the pain aggressively and risk worsening the addiction, or prioritize addiction treatment and leave the pain undertreated. These results suggest that the dilemma is partly false. Collaborative care interventions for chronic pain improved pain outcomes and reduced opioid doses in patients with and without potential substance use disorder alike, indicating that substance use disorder status should not gate access to structured pain treatment. As health systems continue to grapple with the twin burdens of chronic pain and the opioid crisis, the message from this trial is that integrated, team-based care can serve both populations, and that excluding patients with substance use disorder from such care is neither necessary nor supported by the evidence.

Subject of Research: Collaborative care treatment outcomes for chronic pain and opioid dose reduction in patients with and without substance use disorder

Article Title: Pain and Opioid Dose Reduction Based on Substance Use Disorder Status: Secondary Analysis from a Pragmatic Effectiveness Trial

Article References: Morasco, B. J., Hammett, P. J., Krebs, E. E., Seal, K. H., DeRonne, B. M., Lovejoy, T. I., Bohnert, A. S. B., Frank, J. W., Makris, U. E., Naylor, J. C., Painter, J. T., Borsari, B., Hagedorn, H. J., & Becker, W. C. (2026). Pain and Opioid Dose Reduction Based on Substance Use Disorder Status: Secondary Analysis from a Pragmatic Effectiveness Trial. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10816-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10816-6

Keywords: substance use disorder, chronic pain, long-term opioid therapy, opioid dose reduction, collaborative care, pragmatic trial, veterans health, pain interference, pain intensity, primary care, comparative effectiveness, opioid prescribing

The study, conducted by İsmail Aşatır and Atiye Erbaş of Duzce University’s Department of Surgical Nursing, enrolled 122 patients at the orthopedic clinic of a tertiary university hospital between November 2023 and February 2024. Participants were randomly assigned in equal numbers to an intervention group and a control group, with 61 patients in each arm. Those in the intervention group received a structured preoperative pain education program delivered by nurses, while the control group received the standard care normally provided at the clinic. The trial was prospectively registered with ClinicalTrials.gov under identifier NCT06104254 on 23 October 2023, before participant enrollment began, a detail that strengthens confidence in the integrity of the randomization protocol.

The researchers tracked two primary outcomes: the intensity of pain patients reported after surgery, measured on the Numeric Rating Scale, and the patients’ pain beliefs, assessed with the Pain Beliefs Scale. The Pain Beliefs Scale distinguishes between two fundamentally different ways of thinking about pain. Psychological pain beliefs frame pain as something influenced by thoughts, emotions, and mental states, whereas organic pain beliefs attribute pain entirely to physical injury and tissue damage. This distinction matters because a growing body of pain science suggests that patients who understand pain as modifiable, rather than as a pure readout of bodily harm, tend to cope better and report less severe pain.

To analyze their data, the team used linear mixed-effects models, a statistical approach well suited to repeated measurements collected over time. Rather than comparing groups only at a single moment, mixed-effects models can capture how outcomes evolve across multiple postoperative time points and can test whether the two groups followed different trajectories. The key quantity in such analyses is the group-by-time interaction, which asks whether the change over time in one group differs statistically from the change over time in the other. A significant interaction is the signature of diverging paths, not merely a difference in a snapshot.

That is precisely what the researchers found for postoperative pain intensity. The linear mixed-effects model demonstrated a significant group-by-time interaction, indicating that pain followed genuinely different trajectories in the intervention and control groups. In practical terms, patients who had received structured preoperative pain education from nurses experienced a more favorable course of postoperative pain than those who received standard care alone. For a field in which postoperative pain management still relies heavily on escalating analgesic regimens, the idea that a conversation before surgery can bend the pain curve is striking.

The effects on pain beliefs were more nuanced. The analysis revealed a significant group-by-time interaction for psychological pain beliefs, meaning the education program produced measurable shifts in how patients conceptualized the psychological dimension of pain. Patients who had been educated came to view pain as something their thoughts and coping strategies could influence, a reframing that aligns with modern biopsychosocial models of pain. However, no significant intervention effect was found for organic pain beliefs. In other words, the program successfully updated patients’ understanding of the psychological side of pain but did not alter their conviction that pain fundamentally originates in physical injury, which the researchers suggest may be a more entrenched belief to shift.

The trial also examined several secondary factors. Pain intensity tended to be higher among women and among patients who reported fear of pain before their operations, although these differences did not reach statistical significance in the analysis. The directional pattern is nonetheless consistent with a wider literature linking preoperative pain catastrophizing and anxiety to worse postoperative outcomes, and it hints that patients who arrive frightened may be precisely those who benefit most from reassurance and preparation. Larger trials would be needed to determine whether these subgroup patterns are real effects or statistical noise.

What makes the findings compelling is the simplicity of the intervention relative to its reach. Preoperative education requires no new drugs, no additional hardware, and no change to surgical technique. It asks nurses to spend time before surgery explaining what patients should expect, how pain can be managed, and what role their own beliefs and behaviors play in recovery. Orthopedic wards are staffed by nurses who already interact with patients in the preoperative window, so embedding structured pain education into that existing contact represents a marginal cost for a potentially substantial gain in patient comfort, mobility, and possibly even length of stay.

The authors conclude that preoperative nursing education was associated with reduced postoperative pain intensity and favorable changes in psychological pain beliefs, though not in organic pain beliefs, and they suggest that structured preoperative pain education be considered as part of routine perioperative nursing care to improve postoperative pain management. The research received no specific grant from any funding agency and was approved by the Ethics Committee of the Faculty of Medicine at Duzce University, with the trial conducted in accordance with the Declaration of Helsinki.

Limitations and open questions remain. The study was conducted at a single tertiary center in one country, and the generalizability of the effect to other health systems, surgical populations, and cultural contexts will need to be tested. The incomplete shift in organic beliefs suggests that education programs might be strengthened by directly addressing the intuitive but incomplete equation of pain with tissue damage. Still, the trial adds to mounting evidence that the mind’s framing of pain is not a passive bystander in recovery. As health systems search for affordable ways to improve surgical outcomes, this study suggests one of the most powerful tools available may be a well-informed nurse and a few crucial minutes before the operation begins.

Subject of Research: Effect of preoperative nurse-led pain education on postoperative pain and pain beliefs in orthopedic surgical patients

Article Title: The effect of preoperative nursing education on postoperative pain intensity and pain beliefs in orthopedic surgical patients: randomized controlled trial

Article References: The effect of preoperative nursing education on postoperative pain intensity and pain beliefs in orthopedic surgical patients: randomized controlled trial. (n.d.). https://doi.org/10.1186/s12912-026-05422-0

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05422-0

Keywords: preoperative education, postoperative pain, orthopedic surgery, pain beliefs, nursing, randomized controlled trial, pain management, pain intensity, perioperative care, Turkey, BMC Nursing, biopsychosocial model