Dobscha SK (Portland VAMC), Corson K
(Portland VAMC), Perrin NA
(School of Nursing, Oregon Health & Science University), Hanson GC
(School of Nursing, Oregon Health & Science University), Leibowitz RQ
(Portland VAMC), Doak MN
(Primary Care Division, Portland VAMC), Dickinson KC
(Portland VAMC), Sullivan MD
(Department of Psychiatry and Behavioral Sciences, University of Washington), Gerrity MS
Chronic pain is common in primary care patients and associated with distress, disability, and increased healthcare utilization. The objective of this project was to determine the extent to which a collaborative intervention, “Assistance with Pain Treatment” (APT), improves chronic pain-related outcomes including comorbid depression severity in a VA primary care setting.
This was a cluster-randomized, controlled trial of APT versus treatment as usual (TAU). Recruitment took place between January 2006 and January 2007. Participants were 42 primary care providers (PCPs) and 401 patients from five primary care clinics of one VAMC. Patients had documented musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or more. PCPs were randomized to APT versus TAU; patients were assigned to the same groups as their PCPs. APT included a PCP education program; patient assessment, education, and activation; symptom monitoring, feedback and recommendations to PCPs; and facilitation of specialty care. Main outcomes were pain-related disability (Roland-Morris Disability Questionnaire [RMDQ], range 0-24), pain intensity and interference (Chronic Pain Grade [CPG] Characteristic Intensity and Interference, range 0-100 each), and depression (Patient Health Questionnaire-9 [PHQ-9], range 0-27).
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.
The APT intervention was significantly more effective than TAU across a variety of outcome measures.
This study demonstrates that a primary-care based intervention can have positive effects on pain disability, pain intensity, and depressive symptoms. Although many improvements were modest, they may be especially meaningful because patients in our sample were older, had long-standing pain, multiple medical problems, and high baseline rates of disability.