Making Integrated Multimodal Pain Care a Reality: A Path Forward

Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial

ABSTRACT

Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.

Healthcare Access and Delivery During the COVID-19 Pandemic for Black Veterans with Chronic Pain: a Qualitative Study

BACKGROUND

The COVID-19 pandemic led to significant disruptions in healthcare and rapid increases in virtual healthcare delivery. The full effects of these shifts remain unknown. Understanding effects of these disruptions is particularly relevant for patients with chronic pain, which typically requires consistent engagement in treatment to maximize benefit, and for Black patients, given documented racial disparities in pain treatment and telehealth delivery.

OBJECTIVE

To understand how Black patients with chronic pain experienced pandemic-related changes in healthcare delivery.

DESIGN

In-depth, semi-structured qualitative interviews PARTICIPANTS: Black veterans with chronic pain.

KEY RESULTS

Participants described decreased ability to self-manage their chronic pain, obtain nonpharmacological services such as physical therapy, see their primary care providers, and schedule surgery. Most did not believe telehealth met their needs, describing feeling inadequately assessed for their pain and noting that beyond renewing prescriptions, telehealth visits were not that useful. Some believed their communication with their providers suffered from a lack of in-person contact. Others, however, were willing to accept this tradeoff to prevent possible exposure to COVID-19, and some appreciated the convenience of being able to access healthcare from home.

CONCLUSIONS

Black patients with chronic pain described mostly negative effects from the shift to telecare after the pandemic's onset. Given existing disparities and likely persistence of virtual care, research on the longer-term effects of virtual pain care for Black patients is needed.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability. PERSPECTIVE: We evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.

A Comprehensive, Multimodal, Interdisciplinary Approach to Chronic Non-Cancer Pain Management in a Family Medicine Clinic: A Retrospective Cohort Review

INTRODUCTION

The complexity of chronic non-cancer pain in the setting of regulatory efforts to curb opioid usage presents a novel challenge for the medical community. Much of this burden falls on primary care clinics. We retrospectively quantified the reduction of opioid usage by patients in a multimodal, interdisciplinary, primary care clinic for chronic pain.

METHODS

A multimodal, interdisciplinary, chronic pain clinic embedded in a large academic military family medicine clinic operated one-half day weekly to address referrals from within the clinic at large. Appointment times were longer than typical primary care appointments. The clinic was equipped with support staff, ancillary specialty providers, and non-pharmacologic complementary treatment resources. A retrospective cohort review was conducted on 78 patients referred to this clinic from March 1, 2015 (the inception date of the clinic) through December 31, 2015.

RESULTS

Fifty-four of 78 patients met inclusion criteria. Overall mean morphine equivalent daily dosing (MEDD) dropped from 31.5 MEDD to 20.5 MEDD (p = 0.0005) 12 months post-intervention and from 31.5 MEDD to 9.5 MEDD (p < 0.0001) 36 months post-intervention. Four patients with a high mean baseline opioid dose of 185.2 MEDD dropped to 29.9 MEDD 36 months post-intervention. The mean 0-10 pain score decreased from 5.3 ± 2.2 to 4.0 ± 2.5 (p = 0.001).

CONCLUSION

A multimodal, interdisciplinary, primary care-based, chronic pain clinic equipped with extended appointment times, non-pharmacologic treatment resources, and specialty access can curb opioid usage. Leadership support for protracted appointment duration, complementary treatment resources, and interdisciplinary personnel is crucial to success.

Women Veterans' Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study

OBJECTIVES

Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans' needs.

DESIGN

Qualitative, interview-based study.

SETTING

San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management.

SUBJECTS

Women with chronic pain who completed ≥3 IPT sessions.

METHODS

Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews.

RESULTS

Fourteen women veterans (mean age 51 years; range 33-67 years) completed interviews. Interviews revealed several factors impacting women veterans' experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities.

CONCLUSIONS

Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women's health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.

Inhibition of the Soluble Epoxide Hydrolase as an Analgesic Strategy: A Review of Preclinical Evidence

Chronic pain is a complicated condition which causes substantial physical, emotional, and financial impacts on individuals and society. However, due to high cost, lack of efficacy and safety problems, current treatments are insufficient. There is a clear unmet medical need for safe, nonaddictive and effective therapies in the management of pain. Epoxy-fatty acids (EpFAs), which are natural signaling molecules, play key roles in mediation of both inflammatory and neuropathic pain sensation. However, their molecular mechanisms of action remain largely unknown. Soluble epoxide hydrolase (sEH) rapidly converts EpFAs into less bioactive fatty acid diols in vivo; therefore, inhibition of sEH is an emerging therapeutic target to enhance the beneficial effect of natural EpFAs. In this review, we will discuss sEH inhibition as an analgesic strategy for pain management and the underlying molecular mechanisms.

Systematic scoping review of interactions between analgesic drug therapy and mindfulness-based interventions for chronic pain in adults: current evidence and future directions

Supplemental Digital Content is Available in the Text.

None of the mindfulness-based clinical trials for chronic pain included in this review analyzed the interaction effects between mindfulness interventions and concomitant analgesic drug therapies.

Most patients with chronic pain do not find adequate pain relief with a single treatment, and accumulating evidence points to the added benefits of rational combinations of different treatments. Given that psychological therapies, such as mindfulness-based interventions (MBIs), are often delivered in conjunction with concomitant analgesic drug therapies (CADTs), this systematic scoping review examines the evidence for any interactions between MBIs and CADTs. The protocol for this review has been published and registered. MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and PsycINFO databases were searched until July 2019. We included randomized controlled trials that evaluated the efficacy of MBIs for the treatment of chronic pain. A total of 40 randomized controlled trials (2978 participants) were included. Thirty-nine of 40 (97.5%) included mindfulness-based clinical trials allowed the use of CADTs. However, only 6 of these 39 (15.4%) trials provided adequate details of what these CADTs were, and only 4 (10.3%) trials controlled for CADTs. Of great relevance to this review, none of the included trials analyzed the interactions between MBIs and the CADTs to determine whether they have an additive, synergistic, or antagonistic effect on chronic pain. Adverse events were inconsistently reported, and no judgment could be made about safety. Future trials assessing the interactions between MBIs and CADTs, with better harms reporting, are needed to better define the role of MBIs in the management of chronic pain.

Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada

BACKGROUND

Multidisciplinary pain treatment facilities (MPTFs) are considered the optimal settings for the management of chronic pain (CP). This study aimed (1) to determine the distribution of MPTFs across Canada, (2) to document time to access and types of services, and (3) to compare the results to those obtained in 2005-2006.

METHODS

This cross-sectional study used the same MPTF definition as in 2005-2006-that is, a clinic staffed with professionals from a minimum of three different disciplines (including at least one medical specialty) and whose services were integrated within the facility. A comprehensive search strategy was used to identify existing MPTFs across Canada. Administrative leads at each MPTF were invited to complete an online questionnaire regarding their facilities.

RESULTS

Questionnaires were completed by 104 MPTFs (response rate 79.4%). Few changes were observed in the distribution of MPTFs across Canada compared with 12 years ago. Most (91.3%) are concentrated in large urban cities. Prince Edward Island and the Territories still lack MPTFs. The number of pediatric-only MPTFs has nearly doubled but remains small (n=9). The median wait time for a first appointment in publicly funded MPTFs is about the same as 12 years ago (5.5 vs 6 months). Small but positive changes were also observed.

CONCLUSION

Accessibility to public MPTFs continues to be limited in Canada, resulting in lengthy wait times for a first appointment. Community-based MPTFs and virtual care initiatives to distribute pain services into regional and remote communities are needed to provide patients with CP with optimal care.

The effect of music on pain sensitivity in healthy adults

BACKGROUND

Previous work suggests mediating effects of music on acute pain processing. This quasi-experimental pilot study examined the effects of music on experimental pain sensitivity.

METHODS

Healthy adults (N = 40) completed quantitative sensory tests during three music conditions (silence, listening, and singing). Repeated Measures ANOVA , Friedman's Test, and post hoc comparisons determined differences in pain intensity and time to cold pain threshold and tolerance between conditions.. Pearson partial correlations evaluated the association of musical factorswith pain sensitivity.

RESULTS

Participants demonstrated longer time intervals until perceiving pain and tolerated pain for longer durations when singing compared to listening. Greater self-reported singing proficiency was associated with higher tolerance. Several musical factors were significantly correlated with time from pain threshold to reaching tolerance.

CONCLUSION

Singing during an acute painful stimulus may increase tolerance. Various musical characteristics impact volunteers' central pain responses and singing may be an important adjunct pain management strategy.

Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings

BACKGROUND

Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans.

OBJECTIVES

We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings.

RESEARCH DESIGN

Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies.

SUBJECTS

Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings.

RESULTS

At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design.

CONCLUSIONS

A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.

Opioid Reduction and Risk Mitigation in VA Primary Care: Outcomes from the Integrated Pain Team Initiative

BACKGROUND

National guidelines advise decreasing opioids for chronic pain, but there is no guidance on implementation.

OBJECTIVE

To evaluate the effectiveness of an Integrated Pain Team (IPT) clinic in decreasing opioid dose and mitigating opioid risk.

DESIGN

This study prospectively compared two matched cohorts receiving chronic pain care through IPT (N = 147) versus usual primary care (UPC, N = 147) over 6 months. Patients were matched on age, sex, psychiatric diagnoses, and baseline opioid dose.

PATIENTS

Veterans receiving care at a VA medical center or VA community-based clinics.

INTERVENTION

Interdisciplinary IPT, consisting of a collocated medical provider, psychologist, and pharmacist embedded in VA primary care providing short-term biopsychosocial management of veterans with chronic pain and problematic opioid use.

MAIN MEASURES

Change in opioid dose expressed as morphine equivalent daily dose (MEDD) and opioid risk mitigation evaluated at baseline, 3 months, and 6 months.

KEY RESULTS

Compared with veterans receiving UPC, those followed by IPT had a greater mean MEDD decrease of 42 mg versus 8 mg after 3 months and 56 mg versus 17 mg after 6 months. In adjusted analysis, compared with UPC, veterans in IPT achieved a 34-mg greater mean reduction at 3 months (p = 0.002) and 38-mg greater mean reduction at 6 months (p = 0.003). Nearly twice as many patients receiving care through IPT versus UPC reduced their daily opioid dose by ≥50%, representing more than a two-fold improvement at 3 months, which was sustained at 6 months [odds ratio = 2.03; 95% CI = 1.04-3.95, p = 0.04]. Significant improvements were also demonstrated in opioid risk mitigation by 6 months, including increased urine drug screen monitoring, naloxone kit distribution, and decreased co-prescription of opioids and benzodiazepines (all p values < 0.001).

CONCLUSIONS

Interdisciplinary biopsychosocial models of pain care can be embedded in primary care and lead to significant improvements in opioid dose and risk mitigation.

An Integrated Pain Team Model: Impact on Pain-Related Outcomes and Opioid Misuse in Patients with Chronic Pain

Objective

Biopsychosocial integrated pain team (IPT) care models are being implemented in Veterans Health Administration (VA) and other health care systems to address chronic pain and reduce risks related to long-term opioid therapy, with little evaluation of effectiveness to date. We examined whether IPT improves self-reported pain-related outcomes and opioid misuse.

Design

Single-group quality improvement study.

Setting

Large VA health care system.

Subjects

Veterans with chronic pain (N = 99, 84% male, mean age [SD] = 60 [13] years).

Methods

Using paired t tests and Wilcoxon matched-pairs signed-ranks tests, we examined pain experience (Brief Pain Inventory, Pain Catastrophizing Scale), opioid misuse (Current Opioid Misuse Measure), treatment satisfaction (Pain Treatment Satisfaction Scale), and pain management strategies among patients with chronic pain before and after three or more IPT encounters.

Results

After an average (SD) of 14.3 (9) weeks engaged in IPT, patients reported improvement in pain interference (mean [SD] = 46.0 [15.9] vs 40.5 [16.2], P &lt; 0.001), pain catastrophizing (mean [SD] = 22.9 [13.0] vs 19.3 [14.1], P = 0.01), treatment satisfaction (i.e., “very satisfied” = 13.1% at baseline vs 25.3% at follow-up, P = 0.01), and reduced opioid misuse (mean [SD] = 11.0 [7.5] vs 8.2 [6.1], P = 0.01). Patients reported increased use of integrative (i.e., acupuncture, 11% at baseline vs 26% at follow-up, P &lt; 0.01) and active pain management strategies (i.e., exercise, 8% at baseline vs 16% at follow-up, P &lt; 0.01) and were less likely to use only pharmacological pain management strategies after IPT engagement (19% at baseline vs 5% at follow-up, P &lt; 0.01).

Conclusions

Biopsychosocial, integrated pain care may improve patient-centered outcomes related to opioid misuse and the subjective experience and nonpharmacological self-management of chronic pain.

Patient Experiences With Integrated Pain Care: A Qualitative Evaluation of One VA's Biopsychosocial Approach to Chronic Pain Treatment and Opioid Safety

Background

Mounting concern about the risks and limited effectiveness of opioid therapy for chronic pain has spurred the implementation of novel integrated biopsychosocial pain care models in health-care systems like the Department of Veterans Affairs (VA). However, little is known about patient experiences with these new care models.

Objective

We conducted a qualitative study to examine patient experiences with a pain care model currently being disseminated at the VA: interdisciplinary, integrated pain teams (IPTs) embedded in primary care.

Method

We interviewed 41 veterans who received care from VA’s first IPT to learn how working with the team impacted their pain care and quality of life. We asked about their overall experience with IPT, what worked and did not work for them, and what changes they would recommend to improve IPT care.

Results

The interviews revealed a wide spectrum of patient experiences and varying perspectives on the extent to which the new model improved their pain and quality of life. Thematic analysis shed light on factors impacting patients’ experiences, including pretreatment goals and expectations as well as attitudes toward opioids and nonpharmacological treatments.

Conclusion

We discuss the implications of our findings for national efforts to implement biopsychosocial pain care, and we offer recommendations to promote patient-centered implementation.