Getting "Unstuck": A Multi-Site Evaluation of the Efficacy of an Interdisciplinary Pain Intervention Program for Chronic Low Back Pain

Rate and Predictors of Patients with Chronic Pain Establishing Care with Pain Psychology Following Pain Physician Referral

OBJECTIVE

To determine, among patients with chronic pain who had received pain physician referral to pain psychology, the rate of establishing care and factors related to establishing care with pain psychology.

DESIGN

Retrospective study.

SETTING

Academic tertiary care center.

SUBJECTS

Patients from the University of California, San Diego (UCSD) Center for Pain Medicine.

METHODS

This was an institutional review board-approved, retrospective study of 150 consecutive referrals of unique patients from UCSD Pain Medicine to UCSD Pain Psychology.

RESULTS

Of 150 patients referred to pain psychology, 74 (49.3%) established care with pain psychology. Of 98 patients who had previously seen mental health services, 58 established care with pain psychology (59.2%; 95% confidence interval [CI]: 49% to 69%), whereas of 52 patients who had not previously seen mental health services, 16 established care with pain psychology (30.8%; 95% CI: 18% to 43%) (odds ratio [OR] 3.26; 95% CI: 1.60 to 6.66). In the patient subset with depression and/or anxiety, of 82 patients who had previously seen mental health services, 47 established care with pain psychology (57.3%; 95% CI: 47% to 68%), whereas of 20 patients who had not previously seen mental health services, three established care with pain psychology (15%; 95% CI: -1% to 31%) (OR 7.61; 95% CI: 2.07 to 28.01). Of 96 patients referred for general pain psychology evaluations, 43 established care (45%; 95% CI: 35% to 55%), whereas of 38 patients referred for preprocedural evaluation for an implantable device, 24 established care (63%; 95% CI: 48% to 78%).

CONCLUSION

Patients are significantly more likely to establish care with pain psychology if they have previously seen a mental health professional. This was even more marked among the patient subset with a history of depression and/or anxiety who had engaged in mental health services than among those with a history of depression and/or anxiety who had not engaged in mental health services. Whether referral was for general psychological evaluation or preprocedural evaluation for an implantable device did not significantly influence whether patients established care. Targeted interventions are needed to improve the likelihood of patients engaging with pain psychology services.

An interdisciplinary program for familiar faces with chronic pain visiting the emergency department-randomized controlled trial

OBJECTIVES

To evaluate the effect of a collaborative interdisciplinary pain assessment program on pain and health-related quality of life among individuals with chronic pain who frequently visit the emergency department (ED).

METHODS

Individuals with chronic pain who frequented the ED (ie, ≥8 visits within the previous 12 months) were randomly assigned to a collaborative chronic pain management program or treatment as usual. Primary outcomes were change in physical function and visits to the ED from baseline to 12 months using validated measures. Secondary measures included physical and emotional functioning, insomnia, health-related quality of life, risk of aberrant opioid use, and health care use. Mixed model analyses of variances were used to evaluate intervention effectiveness among the whole sample (ie, using intention to treat principles) and individuals who completed more than 50% of follow-up assessments.

RESULTS

One hundred participants were assessed for eligibility and 46 patients were enrolled with 24 being randomized to intervention and 22 to treatment as usual (TAU). Eleven of the 24 patients randomized to the intervention were lost to follow-up and 3 withdrew participation. Two of the 22 patients randomized to TAU were lost to follow-up, and 7 withdrew. Although patients assigned to the intervention improved more rapidly on measures of pain and health related quality of life, both groups had similar improvements overall between baseline to 12 months. Average pain intensity reduction (numeric rating scale [SE]) was 4.63 (0.40) in the intervention and 4.82 (0.53) in the treatment as usual at the 12-month follow-up. A significant group × time interaction was present for risk of aberrant opioid use, with individuals in the intervention group reporting greater improvement in risk of aberrant opioid use by 12-month follow-up.

CONCLUSION

Participation in an interdisciplinary program may accelerate improvements in pain- and health-related quality of life and reduce risk of aberrant opioid use to manage pain and related distress. Further research is needed to better understand and address barriers to engagement in chronic pain care.

Power over pain - An interprofessional approach to chronic pain: Program feedback from a medically underserved community

INTRODUCTION

The management of chronic pain is challenging. Biopsychosocial models recommend interprofessional approaches to treatment, but there is sparse information about participants' experiences of these programs, especially in medically underserved populations coping with the intersectionality of racial bias, low socioeconomic status, and psychosocial stressors. This study explored the perspectives and experiences of black participants with low socioeconomic status and concomitant psychosocial stressors in an outpatient interprofessional pain management program, Power over Pain. The program incorporates cognitive-behavioural techniques, creative arts therapies, pain education, and psychoeducation about stress management, self-care, exercise, and medication.

METHOD

This study employed thematic analysis as the qualitative research method. We conducted semi-structured interviews with nine program participants. Interview questions focused on the impact of the program on participants' overall health and wellbeing and ability to manage chronic pain.

RESULTS

Thematic analysis revealed the following treatment benefits as perceived by the participants: (a) moving from feeling stuck to feeling empowered, (b) enhanced understanding of chronic pain resulting in cognitive reframing and debunking certain myths and stigmas, (c) learning new pain management strategies, and (d) social support.

CONCLUSION

The findings suggest that the Power over Pain program may be an effective way to improve self-management and empower medically underserved people who have chronic pain.

Structural MRI Analysis of Chronic Pain Patients Following Interdisciplinary Treatment Shows Changes in Brain Volume and Opiate-Dependent Reorganization of the Amygdala and Hippocampus

OBJECTIVE

The present study examined pre- to post-treatment changes in volumes for brain structures known to be associated with pain processing (thalamus, caudate, putamen, pallidum, hippocampus, amygdala, and accumbens) following an interdisciplinary pain management program.

DESIGN

Twenty-one patients participating in a four-week interdisciplinary pain management program completed the study. The program consisted of individual and group therapies with the following disciplines: physical therapy, occupational therapy, pain psychology, biofeedback/relaxation training, nursing lectures, and medical management. All patients underwent functional magnetic resonance imaging of the brain before the start and at completion of the program. They also completed standard outcome measures assessing pain, symptoms of central sensitization, disability, mood, coping, pain acceptance, and impressions of change.

RESULTS

Our results showed a significant increase in total brain volume, as well as increased volumes in the thalamus, hippocampus, and amygdala. As expected, we also found significant improvements in our standard outcome measures. The majority of patients rated themselves as much or very much improved. The increase in volume in the hippocampus was significantly associated with patient perceptions of change. However, the correlations were in the unexpected direction, such that greater increases in hippocampal volume were associated with perceptions of less improvement. Further exploratory analyses comparing patients by their opioid use status (use vs no use) showed differential program effects on volume increases in the hippocampus and amygdala.

CONCLUSIONS

These findings show that a four-week interdisciplinary pain management program resulted in changes in the brain, which adds objective findings further demonstrating program efficacy.

Implementation of the Ottawa Hospital Pain Clinic stepped care program: A preliminary report

BACKGROUND

Access to multidisciplinary pain management treatment in Canada is limited, with wait times up to 4 years. Stepped care approaches to mental health treatment have led to substantial reduction and elimination of wait times and may be applicable to chronic pain settings. There is no unifying framework for stepped care chronic pain programs. A systematic review of the efficacy of stepped care in chronic pain management conducted by the Canadian Agency for Drugs and Technologies reported varied results that may be due to heterogeneous stepped care models across facilities.

AIM

We propose a unifying framework for multidisciplinary stepped care chronic pain programs and present its application at The Ottawa Hospital Pain Clinic. The Ottawa Hospital stepped care framework is an eight-tiered approach that allows patients the opportunity to decide collaboratively with a health care professional which treatment program will best suit their needs for the management of chronic pain. As levels of stepped care increase, the time and resource commitment to each step will also increase. Treatment is stepped up or down, depending on patient needs.

METHOD

This is a descriptive case study.

RESULTS

Implementing the interprofessional model of care with the stepped care program has eliminated wait times for access to The Ottawa Hospital Pain Clinic Interprofessional Chronic Pain Management Program and has improved communication between professions of the interprofessional team, resulting in better care for patients.

CONCLUSION

More research is needed to further develop and evaluate the clinical efficacy of stepped care to manage chronic pain.

Application of ICD-11 among individuals with chronic pain: A post hoc analysis of the Stanford Self-Management Program

BACKGROUND

Chronic primary pain (CPP) is one of seven diagnostic groups within the proposed classification of chronic pain in ICD-11. Our aims were to apply the proposed ICD-11 criteria in a large cohort of chronic pain patients participating in the Chronic Pain Self-Management Program (CPSMP) and further investigate whether participants with CPP differed from participants with chronic secondary pain (CSP) regarding health, health expenditure and the effect of participating in the CPSMP.

METHODS

A secondary analysis of a randomized, controlled trial on the effect of the CPSMP. Four examiners categorized participants' pain according to ICD-11 using register-based medical diagnoses and patients' self-reported symptoms. Afterwards, differences between CPP and CSP were examined.

RESULTS

Out of 394 participants, 312 were successfully classified into CPP (n = 164) or CSP (n = 148) whereas 76 had a mixed pain condition. Participants with CPP were younger, more likely to be women, and had longer pain duration compared to participants with CSP. Participants with CPP reported worse health-related quality of life on the SF-36 Mental Component Summary and subscales of vitality, social functioning and bodily pain. Participants with CSP had more physical comorbidities and higher total health expenditure. None of the groups benefitted from the CPSMP.

CONCLUSIONS

We successfully applied the new classification of chronic pain in ICD-11 on the basis of ICD-10 medical diagnoses and symptom self-report. Participants with CPP differed significantly from participants with CSP on baseline characteristics, self-reported health measures and total health expenditure. The CPSMP was not effective in any of the groups.

SIGNIFICANCE

The current study applies the proposed new classification of chronic pain in ICD-11 and shares the experiences of the diagnostic rating procedure of individuals with chronic pain. Furthermore, it evaluates the effect of the Stanford Self-Management Program.

Impact of Symptom Reporting Agreement on Interdisciplinary Pain Program Participation

OBJECTIVE

To investigate whether physician-patient agreement of potential patient problem areas impacts subsequent patient enrollment in an interdisciplinary pain management program.

DESIGN

Retrospective chart review of 544 patients who underwent evaluation of their chronic pain. Physicians and their patients endorsed perceived patient problems during the evaluation. The potential problems included 7 clinical domains: pain, sleep, mood, physical functioning, ability to cope with pain, ability to manage pain flare-ups, and pain medication effectiveness.

RESULTS

Results indicated statistically significant levels of agreement among the physicians and their patients (free-marginal kappa range, 0.19 to 0.94, P's < 0.001). The highest agreement occurred for pain and the lowest for pain medication effectiveness. Patients who enrolled in a recommended program did not differ from those who did not enroll based on either levels of agreement or average number of physician-patient agreements for the 7 clinical domains (P's > 0.05). Patients recommended for higher-intensity programs were perceived by their evaluating physician to have a significantly greater number of problematic clinical domains than those recommended for less intense pain programs.

CONCLUSION

The level of physician-patient agreement regarding the patients' current difficulties did not appear to influence patients' decisions to participate in interdisciplinary pain management. Extraneous, nonclinical factors may have had a greater impact on participation in interdisciplinary pain management than physician-patient agreement. Future research should focus on identifying these factors and their impact. Also, studying the impact of physician-patient agreement beyond enrollment status (eg, on successful program completion) may be helpful in potentially enhancing patient outcomes.

Impact of a multidisciplinary pain management program on patient care utilization and cost of care

Objective

Chronic pain is a highly prevalent and costly condition with few proven treatment options. Since 2014, Geisinger’s Department of Pain Medicine has implemented the Multidisciplinary Pain Program (MPP), which consists of a 3-day educational seminar followed by 12 months of comprehensive care. This study examines the impact of MPP on care utilization and cost between 2014 and 2016.

Methods

A retrospective health insurance claims data analysis covering a 3-year period between January 2013 and December 2016. Among all patients referred to MPP during the period, a subset of those who were Geisinger Health Plan (GHP) members was identified (113 patients). Those who were GHP members and were referred to MPP after December 2016 served as the contemporaneous comparison group (69 patients). GHP’s claims data for the corresponding period were analyzed on a per-member-per-month (PMPM) basis.

Results

MPP was associated with US$754 PMPM reduction in total cost of care including prescription drug costs (P=0.014) and US$846 reduction in total medical cost excluding prescription drugs (P=0.006). These cost savings were attributable to reductions in utilization of high-end diagnostic imaging (52 per-1,000 members-per month; P=0.015) and acute inpatient admissions (20 per-1,000 members-per month; P=0.086).

Conclusion

Patients enrolled in MPP were less likely to use expensive diagnostic imaging and experienced fewer hospitalizations, resulting in total cost of care savings. These findings are consistent with the expectation that MPP improves health outcomes among patients suffering from chronic pain.