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Thursday, March 19, 2015

Stepped-Care Approach to Chronic Pain Improves Function


A two-step strategy to managing chronic pain in US military veterans was associated with improved function and decreased pain severity, yielding a 30% improvement in pain-related disability, a new study shows.

Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm, coupled with pain self-management strategies. Step 2 comprised 12 weeks of cognitive-behavioral therapy. All components of the intervention were delivered by trained nurse care managers.

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Musculoskeletal pain is one of the chief reasons adults see their primary care physician, Joseph S. Ross, MD, associate editor, JAMA Internal Medicine, points out in an Editor's Note published with the study.

The office encounter "typically starts with a discussion of the patient's symptoms and physical function, continues with advice from the physician to lose weight and engage in rehabilitation exercises, and concludes with a prescription, initially for acetaminophen or a nonsteroidal anti-inflammatory medicine but often escalating to muscle relaxants and opiates. For many patients, an ongoing cycle of physician and physical therapy visits, pill bottles, and discomfort result, without ever settling on a plan that effectively manages their pain," he says.

Dr Ross, from Yale University School of Medicine, New Haven, Connecticut, says while the ESCAPE study intervention might not be entirely generalizable, several aspects can be integrated into any primary care practice, namely the "deliberate analgesic treatment algorithm that requires patients to try several different types of medication therapy before using opiates, the use of nurses rather than physicians to direct and advance treatment, and the importance of treating accompanying mental health symptoms, such as depression, all of which can improve musculoskeletal pain management in primary care."

In an interview, Edward Michna, MD, anesthesiologist and pain specialist at Brigham and Women's Hospital, Boston, Massachusetts, and American Pain Society board member, said the results of the ESCAPE study are no surprise.

"We know that multidisciplinary, multimodal care is the best in chronic pain. Unfortunately, the costs are high and it doesn't seem like anyone really wants to pay for it, including the federal government," he said.

"Multidisciplinary pain centers have been going out of business for years because insurance companies don't think long term and they don't want to pay for it," Dr Michna added.

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