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Original Contribution
March 25, 2009

Collaborative Care for Chronic Pain in Primary Care: A Cluster Randomized Trial

Author Affiliations

Author Affiliations: Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders (Drs Dobscha, Corson, Leibowitz, and Gerrity and Ms Dickinson) and Divisions of Primary Care (Dr Doak) and Hospital and Specialty Medicine (Dr Gerrity), Portland VA Medical Center, Portland, Oregon; Departments of Psychiatry (Drs Dobscha and Corson) and Medicine (Drs Doak and Gerrity) and School of Nursing (Dr Perrin and Ms Hanson), Oregon Health and Science University, Portland; and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Dr Sullivan).

JAMA. 2009;301(12):1242-1252. doi:10.1001/jama.2009.377
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 β 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 β, −0.101 [95% confidence interval {CI}, −0.163 to −0.040]; P = .004 and CPG Pain Intensity subscale β, −0.270 [95% CI, −0.480 to −0.061]; P = .01). Among patients with baseline depression (PHQ-9 score ≥ 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 β, −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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