Collaborative Care for Chronic Pain in Primary Care

TLDR

Chronic pain is common in primary care and is linked to distress, disability, and higher health‑care use. The study evaluates whether a collaborative care intervention can improve chronic pain outcomes, including depression severity, in a VA primary‑care setting. In a cluster randomized trial across five VA primary‑care clinics, 42 clinicians and 401 patients with musculoskeletal pain were assigned to either a collaborative pain‑treatment assistance program—comprising clinician education, patient assessment, education, activation, monitoring, feedback, and specialty‑care facilitation—or usual care. Patients receiving the intervention showed greater reductions in pain‑related disability (β = –0.101), pain intensity (β = –0.270), and, among those with baseline depression, depression severity (β = –0.177) over 12 months compared with usual care. ClinicalTrials.gov Identifier: NCT00129480.

Abstract

Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use.To assess whether a collaborative intervention can improve chronic pain-related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting.Cluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008.Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care.Changes over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month).Intervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P = .004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P = .01). Among patients with baseline depression (PHQ-9 score > or = 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P = .003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9.The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures.clinicaltrials.gov Identifier: NCT00129480.