Patients with chronic pain who took part in a collaborative care intervention that included patient and clinician education and symptom monitoring and feedback to the primary care physician had improvements in pain-related disability and intensity, compared to usual care, according to a study in the March 25 issue of JAMA.
Chronic noncancer pain is associated with considerable physical impairment, distress, depression and increased health care use and costs. Many primary care patients report chronic pain, according to background information in the article. Guidelines for chronic pain treatment have been developed, but implementation has been problematic. "Multifaceted, collaborative interventions can promote guideline-concordant care and improve outcomes for chronic conditions in primary care. These interventions, based on the chronic care model, attempt to optimize patient and clinician interactions via education and activation while providing system support, including care management and clinician feedback," the authors write.
Steven K. Dobscha, M.D., of the Portland VA Medical Center, Portland, and colleagues assessed whether a collaborative care intervention would result in improvements in chronic pain-related outcomes, including depression, compared with treatment as usual among 401 patients treated at 5 primary care clinics. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 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. 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.
The researchers found that, through the use of various measurement tools, intervention patients showed significantly greater improvements in pain-related disability and pain intensity compared with treatment as usual patients during a 12-month period. At 12 months, 21.9 percent of intervention patients vs. 14.0 percent of treatment as usual patients demonstrated 30 percent reductions in a measure of pain-related disability.
Compared with treatment as usual patients with depression over 12 months, intervention patients with depression showed significantly greater improvements on a measurement of depression. Intervention patients also reported significantly improved ratings of impression of change at 6 months and 12 months compared with treatment as usual patients.
"Process measures including greater use of adjunctive pain medications and long-term opioids suggest that the intervention contributed to delivery of guideline-concordant care," the researchers write.
"Overall, this study showed that a collaborative care intervention for chronic pain was significantly more effective than treatment as usual across a variety of outcome measures. Although many of the improvements were modest, they may be especially meaningful because patients in our sample were older, had long-standing pain, multiple medical problems, and reported high baseline rates of disability. Our results add to the growing body of literature suggesting that the collaborative care model is effective in improving clinical outcomes and adherence to treatment guidelines across a variety of chronic conditions. Patients in many health care systems and private group practices have limited access to specialty chronic pain services. A primary care-based intervention can have positive effects on pain disability and intensity, and on depressive symptoms," the authors conclude.
(JAMA. 2009;301:1242-1252. Available pre-embargo to the media at www.jamamedia.org)
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