Collaborative Care for Chronic Pain in Primary Care: A Cluster Randomized Trial
Abstract
CONTEXT: Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use. OBJECTIVE: To assess whether a collaborative intervention can improve chronic pain-related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008. INTERVENTION: Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care. MAIN OUTCOME MEASURES: Changes over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month). RESULTS: Intervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P = .004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P = .01). Among patients with baseline depression (PHQ-9 score > or = 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P = .003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9. CONCLUSION: The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00129480.
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Collaborative interdisciplinary care improves management of depression, anxiety, pain, and substance abuse in primary care.
“Several studies demonstrate that collaborative interdisciplinary care improves management of depression, anxiety, pain, and substance abuse in primary care. 14-18”
Collaborative interventions produce modest but statistically significant improvement in outcomes in patients with chronic pain.
“Collaborative interventions, where the therapeutic relationship between patients and doctors is emphasized, have been shown to produce modest but statistically significant improvement in outcomes in patients with chronic pain [66].”
From Identification and Management of Chronic Pain in Primary Care: a Review (2016) · cites this paper as [66]
Collaborative care and stepped care are two care model paradigms for which there is evidence for efficacy/effectiveness.
“This workgroup identified two care model paradigms for which there is evidence for efficacy/effectiveness: collaborative care , where a care manager (e.g., nurse or pharmacist) teams with a physician to provide consultative, multi-modal pain care 27,28 , and stepped care , in which a care manager, following a defined algorithm, guides patients through a sequence of multi-modal treatments. 29”
From A Research Agenda for Advancing Non-pharmacological Management of Chronic Musculoskeletal Pain: Findings from a VHA State-of-the-art Conference (2018) · cites this paper as [28]
Collaborative care and stepped care are two care model paradigms for which there is evidence for efficacy/effectiveness.
“This workgroup identified two care model paradigms for which there is evidence for efficacy/effectiveness: collaborative care , where a care manager (e.g., nurse or pharmacist) teams with a physician to provide consultative, multi-modal pain care 27,28 , and stepped care , in which a care manager, following a defined algorithm, guides patients through a sequence of multi-modal treatments. 29”
From A Research Agenda for Advancing Non-pharmacological Management of Chronic Musculoskeletal Pain: Findings from a VHA State-of-the-art Conference (2018) · cites this paper as [27]
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- Authors
- Dobscha, S. K., Corson, K., Perrin, N. A., Hanson, G. C., Leibowitz, R. Q., Doak, M. N., Dickinson, K. C., Sullivan, M. D., & Gerrity, M. S.
- Affiliations
- Oregon Health & Science University (US)
- Portland VA Medical Center (US)
- University of Washington (US)
- Corresponding author
- Dobscha, Steven K.
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2009-03-25
- Volume
- 301
- Issue
- 12
- Pages
- 1242
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2020229129
- Cited by
- 330
- References
- 54
- Citations by year
- 2026: 5 · 2025: 11 · 2024: 12 · 2023: 11 · 2022: 17 · 2021: 20 · 2020: 15 · 2019: 13 · 2018: 28 · 2017: 19 · 2016: 20 · 2015: 21 · 2014: 27 · 2013: 27 · 2012: 27
- FWCI
- 19.88
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Keywords
- chronic pain, collaborative care, primary care, musculoskeletal pain, pain-related disability, pain intensity, depression severity, clinician education, patient activation, specialist referral, veterans, Department of Veterans Affairs
- MeSH terms
- Aged, Ambulatory Care Facilities, Chronic Disease, Depression, Disability Evaluation, Female, Humans, Male, Middle Aged, Outcome and Process Assessment, Health Care, Pain, Pain Measurement, Patient Care Team, Patient Education as Topic, Primary Health Care, Severity of Illness Index, United States, United States Department of Veterans Affairs, Comorbidity, Patient-Centered Care, Pain Management
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