Collaborative care for chronic pain in primary care: A cluster randomized trial. JAMA, 301, 1242-1252

Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders, Portland, OR, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 04/2009; 301(12):1242-52. DOI: 10.1001/jama.2009.377
Source: PubMed


Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use.
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.
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.
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.
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).
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.
The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures. Identifier: NCT00129480.

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Available from: Ginger Hanson, Jan 10, 2015
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    • "No doubt that such complementary and alternative interventional medical procedure can be added to those programs designed to improve and manage chronic pains. Examples of collaborative interventional programs that include patients and clinicians in health education, symptom monitoring and feedback to the primary care providers, and improvements in pain-related disability and intensity, compared to usual care ones was fully demonstrated (Dobscha et al., 2009). Furthermore, being a sort of economical and effective method, cupping therapy can be employed to alleviate or even cure nonspecific low back pains (NLBPs), therefore it might be recommended to be included and incorporated to treat and prevent all related NLBPs (Hong et al., 2006). "
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    ABSTRACT: The present study is designed to determine whether chronic pain syndrome (lower and upper back pain) before and after cupping is the same or there are significant treatment differences. Perception due to cupping of here and now pain sensation; sensation of pain at worst conditions; sensation of pain at best conditions; and tolerated sensation of pain; all before and after cupping were rated on 0 to 10 pain scale. It was hypothesized that there is a significant statistical difference before and after cupping, and cupping is effective in lessening and desensitizing chronic pain among lower and upper back pain subjects. Subjects were drawn on convenience sampling basis, where 95 males and females were recruited for the purpose of investigation. Results indicate that cupping therapy is effective procedure in reducing and alleviating chronic pain, where true statistical differences were obtained. It was found after the study that cupping therapy as an alternative medical technique is an effective and fruitful enough either for the management of upper and lower back pain or the control of such annoying medical conditions.
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    • "Also, specific relapse prevention trials could focus on distinctions between patients with and without pain in order to find new strategies to prevent depression relapse in patients with pain. Some evidence has been found for alleviating chronic pain and depressive symptoms with collaborative care initiatives for chronic pain patients [56,57]. Collaborative care trials have proven their efficacy on sustained recovery of depressive disorder and continuation and maintenance therapies can reduce recurrence [58,59]. "
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    ABSTRACT: Background Studies suggest that poor physical health might be associated with increased depression and anxiety recurrence. The objectives of this study were to determine whether specific chronic diseases and pain characteristics are associated with depression and anxiety recurrence and to examine whether such associations are mediated by subthreshold depressive or anxiety symptoms. Methods 1122 individuals with remitted depressive or anxiety disorder (Netherlands Study of Depression and Anxiety) were followed up for a period of four years. The impact of specific chronic diseases and pain characteristics on recurrence was assessed using Cox regression and mediation analyses. Results Chronic diseases were not associated with recurrence. Neck (HR 1.45, p < .01), chest (HR 1.65, p < .01), abdominal (HR 1.52, p < .01) pain, an increase in the number of pain locations (HR 1.10, p < .01) and pain severity (HR 1.18, p = .01) were associated with an increased risk of depression recurrence but not anxiety. Subthreshold depressive symptoms mediated the associations between pain and depression recurrence. Conclusions Pain, not chronic disease, increases the likelihood of depression recurrence, largely through its association with aggravated subthreshold depressive symptoms. These findings support the idea of the existence of a mutually reinforcing mechanism between pain and depression and are indicative of the importance of shedding light on neurobiological links in order to optimize pain and depression management.
    BMC Psychiatry 06/2014; 14(1):187. DOI:10.1186/1471-244X-14-187 · 2.21 Impact Factor
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    • "Recently, a trial explored efficacy of collaborative care for MDD and musculoskeletal pain [55] and another trial explored efficacy of collaborative care for chronic pain in the primary care setting [23], both with positive results, but in one study the collaborative intervention was more expensive than care as usual [56]. However, treatment of other chronic pain conditions in depressive patients has, so far, not received much attention. "
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    ABSTRACT: The comorbidity of pain and depression is associated with high disease burden for patients in terms of disability, wellbeing, and use of medical care. Patients with major and minor depression often present themselves with pain to a general practitioner and recognition of depression in such cases is low, but evolving. Also, physical symptoms, including pain, in major depressive disorder, predict a poorer response to treatment. A multi-faceted, patient-tailored treatment programme, like collaborative care, is promising. However, treatment of chronic pain conditions in depressive patients has, so far, received limited attention in research. Cost effectiveness of an integrated approach of pain in depressed patients has not been studied. This article describes the aims and design of a study to evaluate effects and costs of collaborative care with the antidepressant duloxetine for patients with pain symptoms and a depressive disorder, compared to collaborative care with placebo and compared to duloxetine alone. This study is a placebo controlled double blind, three armed randomized multi centre trial. Patients with (sub)chronic pain and a depressive disorder are randomized to either a) collaborative care with duloxetine, b) collaborative care with placebo or c) duloxetine alone. 189 completers are needed to attain sufficient power to show a clinically significant effect of 0.6 SD on the primary outcome measures (PHQ-9 score). Data on depression, anxiety, mental and physical health, medication adherence, medication tolerability, quality of life, patient-doctor relationship, coping, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months. In the collaborative care conditions a) and b), a care-manager provides Problem Solving Treatment and integrated symptom management guidance with a self-help manual, monitors depressive and pain symptoms, and refers patients to a physiotherapist for treatment according to a 'Graded Activity' protocol. A psychiatrist provides duloxetine or placebo and pain medication according to algorithms, and also monitors pain and depressive symptoms. In condition c), the psychiatrist prescribes duloxetine without collaborative care. After 12 weeks, the patient is referred back to the general practitioner with a consultation letter, with information for further treatment of the patient. This study enables us to show the value of a closely monitored integrated treatment model above usual pharmacological treatment. Furthermore, a comparison with a placebo arm enables us to evaluate effectiveness of duloxetine in this population in a real life setting. Also, this study will provide evidence-based treatments and tools for their implementation in practice. This will facilitate generalization and implementation of results of this study. Moreover, patients included in this study are screened for pain symptoms, differentiating between nociceptive and neuropathic pain. Therefore, pain relief can be thoroughly evaluated. Trial registration NTR1089
    BMC Psychiatry 05/2013; 13(1):147. DOI:10.1186/1471-244X-13-147 · 2.21 Impact Factor
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