Stepped Care Intervention Benefits Veterans with Chronic Pain
Chronic pain is a critical health problem among Veterans. Pain was the most frequently reported symptom in Persian Gulf War Veterans and ranged in prevalence between 40% and 50% among OEF/OIF/OND Veterans. Initiated in 1998, the VA Pain Management Strategy established pain management as a national priority. Despite this effort, there have been no intervention studies to treat chronic pain in Veterans of the Iraq and Afghanistan conflicts. Conducted at one VAMC, this randomized controlled trial tested the Evaluation of Stepped Care for Chronic Pain (ESCAPE) intervention in primary care settings that included 12 weeks of analgesic treatment (i.e., acetaminophen, topical analgesics, opioids) coupled with pain self-management strategies (i.e., goal setting, positive self-talk), which was followed by 12 weeks of cognitive behavioral therapy. The primary aim of this study was to determine the effectiveness of the intervention in reducing pain-related disability, pain interference, and pain severity over nine months in OEF/OIF/OND Veterans with chronic (>3 months) and disabling musculoskeletal pain. From 12/07 to 6/11, investigators recruited 241 Veterans: 121 were randomized to the intervention and 120 to usual care (i.e., medications, clinic visits, specialty referrals).
- A stepped-care intervention delivered in primary care that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain compared to usual care. For example, Veterans in the intervention group were more likely to demonstrate at least a 30% improvement in the 24-item Roland Morris Disability Scale by nine months.
- At nine months, the mean decrease from baseline in the Brief Pain Inventory interference score was 0.9 points for Veterans in the usual care group compared to 1.7 points for Veterans in the intervention group. Specifically, a 1.7 point difference in pain score translates to less interference due to pain across 7 areas: mood, physical activity, work, social activity, relations with others, sleep, and enjoyment of life. In addition, the Graded Chronic Pain Scale severity score was reduced by 4.5 and 11.1 points, respectively.
- The mean age of Veterans in this study was 37 years, and the primary site of pain was low back (57%), knee (22%), neck (8%), shoulder (7%), and hip (7%).
- Single-center randomized controlled trials have shown larger treatment effects than multicenter trials; however, the intervention effects observed were comparable to other interventions tested at more than one site.
- The ESCAPE trial tested a multi-modal intervention and used a "bundled" approach to delivery. As a result, investigators were not able to determine the relative efficacy of intervention components and were unable to separate out attentional effects.
Dr. Bair is part of HSR&D's Center for Health Information and Communication (CHIC), Indianapolis, IN.
Bair M, Ang D, Wu J, et al. Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of Iraq and Afghanistan Conflicts: A Randomized Trial. JAMA Internal Medicine. March 9, 2015;e-pub ahead of print.