Stepped-Care Approach to Chronic Pain Improves Function

Megan Brooks

March 19, 2015

A two-step strategy to managing chronic pain in US military veterans was associated with improved function and decreased pain severity, yielding a 30% improvement in pain-related disability, a new study shows.

Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm, coupled with pain self-management strategies. Step 2 comprised 12 weeks of cognitive-behavioral therapy. All components of the intervention were delivered by trained nurse care managers.

Many veterans experience significant long-term pain, and medications alone are "only modestly successful in helping them; current pain treatments haven't made much of a dent," study chief Matthew Bair, MD, from the Richard L. Roudebush Veterans Affairs [VA] Medical Center in Indianapolis, the Regenstrief Institute, and the Indiana University School of Medicine, notes in a statement.

Dr Matthew Bair

The decrease in pain severity and 30% improvement in pain-related disability achieved in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) study are "clinically significant, and we found that improvement lasted for at least nine months," adds Dr Bair, an internist who treats veterans in primary care and previously served for 8 years as a US Army physician.

The ESCAPE study was published online March 9 in JAMA Internal Medicine.

Stepped-Care Strategy

ESCAPE included 241 veterans of the Iraq and Afghanistan wars with chronic musculoskeletal pain of the cervical or lumbar spine or extremities (shoulders, knees, and hips). Their mean age was 36.7 years, and 88.4% were men; 121 were randomly assigned to the stepped-care intervention and 120 to usual care. Patients in the usual care group received educational handouts on musculoskeletal pain, were advised to discuss their pain with their physicians, and kept up their usual medications and office visits.

The stepped-care intervention and usual care groups had similar baseline pain measures. The mean Roland Morris Disability Scale (RMDS) score was 13.9 (range, 0 to 24), which represents moderately severe pain-related disability. Likewise, the mean Brief Pain Inventory (BPI) Pain Interference subscale score of 5.4 (range, 0 to 10) represents moderately severe interference with activities due to pain, and the mean Graded Chronic Pain Scale severity score of 66.2 (range, 0 to 100) signifies moderate pain intensity.

Compared with usual care, the intervention led to significant improvements in all pain outcomes at 9 months, the researchers report. The RMDS score decreased by 1.7 points (95% confidence interval [CI], –2.6 to –0.9) from baseline to 9 months in the usual care group compared with 3.7 points (95% CI, –4.5 to –2.8) in the intervention group (between-group difference, –1.9 points [95% CI, –3.2 to –0.7]; P = .002).

Patients in the stepped-care group were more likely to show at least a 30% improvement in RMDS scores by 9 months (relative risk, 1.52 [95% CI, 1.22 - 1.99]; P < .001), with a number needed to treat of 7.5 for 30% improvement.

The mean decrease in the BPI Pain Interference subscale score was 0.9 points (95% CI, –1.2 to –0.5) points in the usual care group vs 1.7 points (95% CI, –2.1 to –1.3) in the intervention group (between-group difference, ?0.8 points [95% CI, –1.3 to –0.3]; P = .003).

The Graded Chronic Pain Scale severity score was reduced by 4.5 points (95% CI, –7.3 to –1.8) in the usual care group compared with 11.1 points (95% CI, –13.9 to –8.3) in the intervention group (between-group difference, –6.6 points [95% CI, –10.5 to –2.7]; P = .001).

The researchers think the stepped-care strategy used in the ESCAPE study "generalizes especially well to other VA medical centers and other large health care systems outside the VA. However, implementing the approach to smaller community settings or to private settings may be challenging."

Interrupting the Cycle

Musculoskeletal pain is one of the chief reasons adults see their primary care physician, Joseph S. Ross, MD, associate editor, JAMA Internal Medicine, points out in an Editor's Note published with the study.

The office encounter "typically starts with a discussion of the patient's symptoms and physical function, continues with advice from the physician to lose weight and engage in rehabilitation exercises, and concludes with a prescription, initially for acetaminophen or a nonsteroidal anti-inflammatory medicine but often escalating to muscle relaxants and opiates. For many patients, an ongoing cycle of physician and physical therapy visits, pill bottles, and discomfort result, without ever settling on a plan that effectively manages their pain," he says.

Dr Ross, from Yale University School of Medicine, New Haven, Connecticut, says while the ESCAPE study intervention might not be entirely generalizable, several aspects can be integrated into any primary care practice, namely the "deliberate analgesic treatment algorithm that requires patients to try several different types of medication therapy before using opiates, the use of nurses rather than physicians to direct and advance treatment, and the importance of treating accompanying mental health symptoms, such as depression, all of which can improve musculoskeletal pain management in primary care."

In an interview, Edward Michna, MD, anesthesiologist and pain specialist at Brigham and Women's Hospital, Boston, Massachusetts, and American Pain Society board member, said the results of the ESCAPE study are no surprise.

"We know that multidisciplinary, multimodal care is the best in chronic pain. Unfortunately, the costs are high and it doesn't seem like anyone really wants to pay for it, including the federal government," he said.

"Multidisciplinary pain centers have been going out of business for years because insurance companies don't think long term and they don't want to pay for it," Dr Michna added.

The ESCAPE study was supported by a grant from VA Rehabilitation Research & Development. One author reports receiving honoraria from Eli Lilly and Company. The other authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online March 9, 2015. Abstract Editor's Note


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