Telecare Intervention Effective for Improving Chronic Pain

Chronic pain in the back, neck, and other joints due to arthritis and other musculoskeletal disorders is extremely common but difficult to treat. Few clinical trials have examined interventions to improve chronic pain in primary care. In a recent study, researchers sought to determine the effectiveness of a telecare intervention for primary care [JAMA. 2014;312(3):240-248]. The findings showed that primary care specialists who enrolled in a 12-month telecare program optimizing nonopioid medications for chronic pain were twice as likely to see improvement as patients who received usual care for chronic pain.

Pain is the leading cause of work disability and a condition that costs the United States >$600 billion each year in healthcare visits. Musculoskeletal pain accounts for nearly 70 million outpatient visits annually in the United States. Telemedicine strategies for pain care have been proposed but not rigorously tested to date.

The SCOPE [Stepped Care to Optimize Pain Care Effectiveness] trial was a 12-month, randomized, controlled study comparing telephone-delivered collaborative care pain management versus usual care in 250 patients with chronic (≥3 months) musculoskeletal pain of at least moderate intensity (Brief Pain Inventory [BPI] score ≥5). Patients 18 to 65 years of age were enrolled from 5 primary care clinics in a single Veterans Affairs medical center from June 2010 to May 2012, with 12-month follow-up completed by June 2013. The primary outcome measure was the BPI total score, which ranges from 0 to 10 and for which a 1-point change was considered clinically significant. Secondary pain outcomes included BPI interference and severity, global pain improvement, treatment satisfaction, and use of opioids and other analgesics. Assessments were conducted at baseline and at 1, 3, 6, and 12 months.

Patients were randomized to an intervention group (n=124) or to a usual care group (n=126), where members received all pain care as usual from their primary care physicians. The intervention group received 12 months of telecare management that included automated symptom monitoring (ASM) via interactive voice recorded telephone calls (51%) or via the Internet (49%) with an algorithm-guided approach to optimizing pain management. ASM was scheduled weekly for the first month, every other week for months 2 and 3, and monthly for months 4 through 12. Among the cohorts, the mean BPI was 5.2, and patients reported a mean of 8 pain-specific disability days (defined as having to reduce their activity by at least 50%) in the past 4 weeks. Most patients had pain in multiple sites present for many years and previously treated with a median of 5 pain medications from 4 different analgesic classes.

Key findings showed that patients in the intervention group were nearly twice as likely to report at least a 30% improvement in their pain score by 12 months compared with the usual care group (51.7% vs 27.1%, respectively; relative risk [RR], 1.91; 95% confidence interval [CI], 1.36-2.69). Patients in the intervention group compared with the usual care group were also significantly more likely to report global improvement (55.8% vs 31.2%, respectively; RR, 1.8; 95% CI, 1.3-2.4) and only half as likely to report worsening pain by 6 months (19.2% vs 36%, respectively; RR, 0.5; 95% CI, 0.3-0.8). Furthermore, patients in the intervention group compared with the usual care group were also more likely to rate as good to excellent the medication prescribed for their pain (73.9% vs 50.9%, respectively) as well as the overall treatment of their pain (76.7% vs 51.6%, respectively; RR, 1.5; 95% CI, 1.2-1.8 for both). Few patients in either group were started on opioids or had escalation in their opioid dose during the study period.

Study limitations noted by the researchers included that the sample consisted of veterans from a single center; many patients had pain for years that involved several bodily sites; and the comparator group was usual care rather than an
attention control.

In summary, the researchers noted, “Telecare collaborative management substantially increased the proportion of patients with improved chronic musculoskeletal pain. This was accomplished by optimizing nonopioid analgesic medications using a stepped care algorithm and monitoring.”—Eileen Koutnik-Fotopoulos