BACKGROUND/RATIONALE:
Chronic pain is very common, and associated with substantial physical and psychosocial impairment and increased healthcare utilization. Depression is frequently comorbid with pain and limits treatment response. Although standards and guidelines for chronic pain treatment have been developed, implementation of guidelines has been problematic, and chronic pain remains undertreated. Among veterans, there is a high prevalence of chronic pain, and the VHA has created a National Pain Management Strategy to reduce suffering from pain and adopted pain as the "5th vital sign."
OBJECTIVE(S):
The primary objective of this study is to determine to what extent a collaborative intervention improves chronic pain-related outcomes in a VA primary care setting. We will also determine to what extent the intervention affects 1) treatment of comorbid depression, 2) adherence of providers to guidelines for chronic pain, and 3) patient and provider satisfaction and attitudes related to chronic pain treatment.
METHODS:
The study is a randomized, controlled trial of "Assistance with Pain Treatment" (APT) versus usual care and will last 39 months. APT is based on previously studied collaborative interventions for chronic illness, and designed to efficiently deliver data, reminders and resources necessary to optimize primary care provider (PCP) adherence to key treatment guidelines. APT includes provider and patient assessment, education and activation, symptom monitoring, feedback and recommendations, and facilitation of specialty/multidisciplinary care.
400 patients and 46 primary care providers will participate. We will randomize by PCP, and nest patients within PCP intervention status. Participants will be followed for 12 months. To recruit participants, we will mail letters to patients with upcoming primary care appointments, and post and distribute advertising flyers in clinics and other prominent hospital locations. Patients with chart-documented musculoskeletal pain diagnoses who report during phone screening at least moderate pain severity and pain-related dysfunction (Chronic Pain Grade [CPG]) lasting at least 12 weeks will be invited to participate. Patients with terminal illness, or cognitive disorders will be excluded. There will be no restrictions by age or sex. Primary outcomes are Roland-Morris Disability scores and CPG pain severity scale scores at 6 and 12 months. Random effects (multilevel) regression models will be used for the primary analysis. Covariates include age, medical comorbidity, baseline pain severity and function scores, baseline depression severity, and duration of pre-entry opioid treatment. We will explore interrelationships of depression severity, adherence of providers to key guideline criteria, substance abuse status, patient and provider attitudes, and patient outcomes including aberrant opioid-related patient behaviors. We will measure how APT impacts VA healthcare utilization and costs; if the intervention is effective, we will calculate incremental cost-effectiveness.
FINDINGS/RESULTS:
Forty-six primary care clinicians and 401 patients from five primary care clinics participated. No adverse events occurred. At baseline, back and neck pain diagnoses were present in 67% and 65% of patients, respectively. Mean pain duration was 15 years, and mean Roland-Morris Disability score (range 0 to 24) was 14.7 (sd=4.4). Seventeen percent of patients met criteria for major depression, 19%, post-traumatic stress disorder, and 9%, alcohol misuse. In preliminary main effects analyses, intervention patients showed greater improvements in pain-related disability (P=.004) and interference (P=.03), pain intensity (P=.01), and depression (P=.003) over 12 months compared to treatment as usual (TAU) patients.
IMPACT:
This is the first study to rigorously evaluate a collaborative care approach to chronic pain in the VA. Preliminary analyses suggest that our primary care-based collaborative care intervention for chronic pain was significantly more effective than treatment as usual across a variety of outcome measures. Although many improvements were modest, they are meaningful because patients in our sample are older, have long-standing pain, multiple medical problems, and high baseline rates of disability.
PUBLICATIONS:
Journal Articles
- Dobscha SK, Corson K, Flores JA, Cockrell EC, Gerrity MS. Veterans Affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Medicine (Malden, Mass.). 2008; 9: 564-571.
- Morasco BJ, Dobscha SK. Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain. General Hospital Psychiatry. 2008; 30(2): 93-9.
