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PMI 03-195 – HSR Study

PMI 03-195
Improving the Treatment of Chronic Pain in Primary Care
Steven K. Dobscha, MD
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: September 2005 - March 2009
Chronic pain is very common, and associated with substantial impairment and increased healthcare utilization. Implementation of treatment guidelines has been problematic, and chronic pain remains undertreated. Because of the prevalence of chronic pain among veterans, the VHA created a National Pain Management Strategy and adopted pain as the "5th vital sign."

Our primary objective was to determine to what extent a collaborative intervention improves chronic pain-related outcomes (pain-related function, pain severity and depression severity) in a VA primary care setting over six and 12 months. We also investigated to what extent the intervention affected 1) treatment of comorbid depression, 2) adherence of providers to guidelines for chronic pain, 3) patient and provider satisfaction and attitudes related to chronic pain treatment, and 4) incremental benefit (pain disability-free days) and incremental health services costs.

The study was a cluster randomized controlled trial of a collaborative care intervention "Assistance with Pain Treatment" (APT) versus treatment as usual (TAU) at five primary care clinics of one Department of Veterans Affairs Medical Center.

401 patients and 42 primary care clinicians participated. APT included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians and facilitation of specialty care. We randomized clinicians to APT or TAU, and nested patients within clinician intervention status.

Patients were recruited via mailings and advertising flyers; those with chart-documented musculoskeletal pain diagnoses who reported at least moderate pain severity and pain-related function (Chronic Pain Grade [CPG]) lasting at least 12 weeks were invited to participate. Participants completed questionnaires at baseline, 3, 6 and 12 months, with a subset re-assessed at 30 months. Primary outcomes were Roland-Morris Disability scores and CPG pain intensity scale scores over 12 months. Depression was assessed using Patient Health Questionnaire 9 [PHQ-9] scores. Intervention effects on patient outcome variables were tested using intention-to-treat analyses with multilevel models; patient-level covariates of age, sex, baseline depression severity, baseline opioid status (yes/no), and medical morbidity were included. To quantify provider adherence to pain treatment guidelines, we created the Pain Process Measure (PPM), a chart review checklist. Clinicians completed a baseline 23-item survey of attitudes and behaviors related to chronic pain management, job satisfaction, and satisfaction with local pain resources. Patient satisfaction measures included patient-rated global impression of change, global VA health care satisfaction, health-related quality of life, and receipt and rating of effectiveness of VA chronic pain treatment. Pain disability-free days were calculated from Roland-Morris Disability Questionnaire scores. Data on VA treatment costs were obtained from the VA's Decision Support System for all utilization except certain intervention activities that were tracked in a separate study database.

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). Common comorbidities including major depression (18%), post-traumatic stress disorder (17%), and alcohol misuse (16%). Intervention patients had a mean of 10.6 (SD=4.5; median=10) contacts with the APT team over 12 months. Intervention patients showed greater improvements in pain-related disability (RMDQ: baseline 14.6 vs. 14.5; 12 months 13.3 vs. 14.3, P=.004), pain interference (CPG-Interference baseline 49.3 vs. 48.7; 12 months 44.6 vs. 55.1, P=.03) and pain intensity (CPG-Intensity: baseline 67.4 vs. 66.0; 12 months 63.2 vs. 65.6, P=.01) over 12 months compared to TAU patients. Among patients with baseline depression (PHQ-9 >10), there were greater improvements in depression severity scores (PHQ-9: baseline 14.4 vs. 14.4; 12 months 10.6 vs. 13.2, P=.003) compared to TAU patients over 12 months. Intervention patients also reported significantly greater global impression of change at 6 months (p<.001) and 12 months (p<.001) compared to TAU patients. However, there were no significant differences in EQ5D scores, ratings of global healthcare treatment satisfaction, or ratings of pain treatment effectiveness over 12 months when comparing intervention to TAU patients. Participants in the intervention group experienced an average of 16 additional pain disability-free days over the 12-month follow-up window as compared to the usual care participants; this came at an adjusted cost of $364 per day for a typical participant.

This was the first study to rigorously evaluate a collaborative care approach to chronic pain in the VA. Our primary care-based intervention was significantly more effective than TAU 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.

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Journal Articles

  1. Morasco BJ, Duckart JP, Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. Journal of general internal medicine. 2011 Sep 1; 26(9):965-71. [view]
  2. Morasco BJ, Corson K, Turk DC, Dobscha SK. Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. The journal of pain : official journal of the American Pain Society. 2011 Mar 1; 12(3):352-9. [view]
  3. Dobscha SK, Corson K, Perrin NA, Hanson GC, Leibowitz RQ, Doak MN, Dickinson KC, Sullivan MD, Gerrity MS. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA : the journal of the American Medical Association. 2009 Mar 25; 301(12):1242-52. [view]
  4. Thielke S, Corson K, Dobscha SK. Collaborative care for pain results in both symptom improvement and sustained reduction of pain and depression. General hospital psychiatry. 2015 Mar 1; 37(2):139-43. [view]
  5. Denneson LM, Corson K, Dobscha SK. Complementary and alternative medicine use among veterans with chronic noncancer pain. Journal of rehabilitation research and development. 2012 May 10; 48(9):1119-28. [view]
  6. Otis JD, Macdonald A, Dobscha SK. Integration and coordination of pain management in primary care. Journal of Clinical Psychology. 2006 Nov 1; 62(11):1333-43. [view]
  7. Morasco BJ, Dobscha SK. Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain. General hospital psychiatry. 2008 Mar 1; 30(2):93-9. [view]
  8. Corson K, Doak MN, Denneson L, Crutchfield M, Soleck G, Dickinson KC, Gerrity MS, Dobscha SK. Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: results from the study of the effectiveness of a collaborative approach to pain. Pain medicine (Malden, Mass.). 2011 Oct 1; 12(10):1490-501. [view]
  9. Dobscha SK, Leibowitz RQ, Flores JA, Doak M, Gerrity MS. Primary care provider preferences for working with a collaborative support team. Implementation science : IS. 2007 May 30; 2:16. [view]
  10. Dobscha SK, Corson K, Leibowitz RQ, Sullivan MD, Gerrity MS. Rationale, design, and baseline findings from a randomized trial of collaborative care for chronic musculoskeletal pain in primary care. Pain medicine (Malden, Mass.). 2008 Nov 1; 9(8):1050-64. [view]
  11. Morasco BJ, Gritzner S, Lewis L, Oldham R, Turk DC, Dobscha SK. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011 Mar 1; 152(3):488-97. [view]
  12. Dickinson KC, Sharma R, Duckart JP, Corson K, Gerrity MS, Dobscha SK. VA healthcare costs of a collaborative intervention for chronic pain in primary care. Medical care. 2010 Jan 1; 48(1):38-44. [view]
  13. Dobscha SK, Corson K, Flores JA, Tansill EC, Gerrity MS. Veterans affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates. Pain medicine (Malden, Mass.). 2008 Jul 1; 9(5):564-71. [view]
Journal Other

  1. Morasco BJ, Dobscha SK. Impact of comorbid substance use disorder on pain functioning: 12-month follow-up evaluation. [Abstract]. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2010 Apr 1; 39(Suppl):S185. [view]
VA Cyberseminars

  1. Dobscha SK. Collaborative Pain Care: Applications to Returning Veterans. Post-Deployment. Integrated Care Initiative National VA Community of Practice Call. [Cyberseminar]. 2011 Mar 11. [view]
  2. Dobscha SK. Results from a randomized trial of collaborative care for chronic musculoskeletal pain in primary pain. [Cyberseminar]. 2008 Aug 5. [view]
Conference Presentations

  1. Morasco BJ, Duckart J, Dobscha SK. Adherence to Clinical Guidelines for the Use of Chronic Opioid Therapy in Veterans with Chronic Pain Based on Substance Use Disorder Status. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 15; National Harbor, MD. [view]
  2. Dobscha SK. Aligning Care to Treat Pain in Veterans with PTSD: A Demonstration Project. Paper presented at: VA National Pain Management Conference; 2009 Sep 30; New Haven, CT. [view]
  3. Dobscha SK. Assistance with Pain Treatment (APT): A Collaborative Intervention for Pain and Depression in Primary Care. Paper presented at: VA Primary Care Leadership Annual Conference; 2008 Oct 15; Washington, DC. [view]
  4. Dobscha SK. Care Management and Patient Aligned Care Teams (PACT). Paper presented at: VA National Pain Management Conference; 2011 Mar 2; Jacksonville, FL. [view]
  5. Dobscha SK. Design and initial findings from a randomized clinical trial of collaborative care for chronic pain. Paper presented at: VA Pain Research National Summit; 2007 Sep 26; Palm Springs, CA. [view]
  6. Dobscha SK, Flores JA, Leibowitz RQ, Cockrell E, Gerrity MS. Examining relationships between clinician attitudes about chronic pain and opioid prescribing rates. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 23; Arlington, VA. [view]
  7. Morasco BJ, Dobscha SK. Impact of Comorbid Substance Use Disorder on Pain Functioning: 12-Month Follow-Up Evaluation. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2010 Apr 9; Seattle, WA. [view]
  8. Dobscha SK. Pain, Depression and Suicide. Paper presented at: VA National Pain Management Conference; 2011 Mar 2; Jacksonville, FL. [view]
  9. Macey TA, Morasco BJ, Duckart JP, Dobscha SK. Patterns and Correlates of Prescription Opioid Use in OEF/OIF Veterans. Poster session presented at: VA National Pain Management Conference; 2011 Mar 2; Jacksonville, FL. [view]
  10. Dobscha SK, Morasco BJ, Macey T, Duckart J, Deyo RA. Predictors of Opioid Initiation and Long Term Use Among Veterans with Chronic Pain. Poster session presented at: American Psychiatric Association Annual Meeting; 2011 May 16; Honolulu, HI. [view]
  11. Dobscha SK, Leibowitz RQ, Flores JA, Doak M, Gerrity MS. Primary care clinician preferences for communicating with a collaborative intervention team. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 23; Arlington, VA. [view]
  12. Dobscha SK, Corson K, Leibowitz RQ, Sullivan MD, Gerrity MS. Rationale, design and baseline findings from a randomized trial of collaborative care for chronic musculoskeletal pain in primary care. Paper presented at: Academy of Psychosomatic Medicine Annual Meeting; 2007 Nov 15; Amelia Island, FL. [view]
  13. Dobscha SK. Results From a Cluster-Randomized Clinical Trial of Collaborative Care for Chronic Pain. Paper presented at: VA / DoD Evolving Paradigms II OEF / OIF National Conference; 2009 Sep 23; Las Vegas, NV. [view]

DRA: Health Systems
DRE: Treatment - Observational
Keywords: Adherence, Depression, Pain
MeSH Terms: none

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