By Brenda L. Mooney
INDIANAPOLIS – A yearlong VA telecare program to manage chronic pain due to arthritis or other musculoskeletal disorders not only doubled the likelihood of improvement for veterans in the intervention program but also demonstrated that patients receiving usual care were twice as likely to get worse during the same time period.
The study, led by researchers at the Richard L. Roudebush VAMC in Indianapolis optimized non-opioid medications for chronic pain, leading to reduced discomfort and greater satisfaction with care. Results were published recently in the Journal of the American Medical Association.1
“The telecare group was twice as likely to have improvement in their pain over the course of a year, compared to the control group, 52% vs. 27%. On the other hand, twice as many patients in the usual care group got worse over the course of the year, 36% vs. 19%, indicating patients with chronic pain not only may not improve but an important number may get worse without enhanced treatment,” said Kurt Kroenke, MD, who designed and led the Stepped Care to Optimize Pain-care Effectiveness study (SCOPE) study.
“We were able to achieve these largely by adjusting their non-opiate medicines,” Kroenke explained in a video made available by JAMA. “Whereas a third of the patients in both groups were on opiates at the beginning of the trial, less than 4% of patients needed an increase in their opiates or to start opiates. So we were able to achieve this benefit without resorting to changes or starting of opiate medicines.”
He suggested that conditions such as pain can be treated with a telecare approach using automated technology and telephone contact for treatment changes.
“We can achieve this benefit by adjusting treatment other than opiates, and, since opiates are really a controversial issue nowadays, I think that we achieved these benefits without resorting to changes in opiates was an important finding,” Kroenke emphasized.
For the SCOPE study, 250 veterans, ranging in age from 18 to 65, were enrolled. The participants all had reported at least three months of chronic musculoskeletal pain of moderate or greater intensity.
Kroenke described the two main components of the telecare intervention: “First, their pain symptoms were monitored either by automated phone calls or by the Internet regularly over the course a year, and, second, they had contact with a nurse who would go over how they were doing [and] who would meet with me weekly to discuss new patients and patients who weren’t doing so well, so we could decide what adjustments in their treatment might be required.”
Automated symptom monitoring — with 51% of patients selecting interactive voice-recorded phone calls and 49% using the Internet — was scheduled weekly for the first month, every other week for in the second and third months , then monthly for the fourth through 12th months.
Outcomes documented included total pain scores and the brief pain inventory as well as overall improvement and use of medications, particularly opiates, he added. Nurse care manager/physician pain specialist teams primary selected from six categories of pain relievers. Those included:
- simple analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs;
- tricyclic antidepressants (amitriptyline and nortriptyline) and cyclobenzaprine (which has a chemical structure quite similar to that of amitriptyline);
- gabapentoids (gabapentin and pregabalin); topical analgesics; and
Results indicated that the benefits did not vary by age or race of study participant. Although one-third of patients were on opioid therapy before the yearlong study began, only a few patients, 4%, were prescribed opioids for the first time or had escalations in opioid dosage.
“The SCOPE trial has several key findings,” study authors wrote. “First, the collaborative telecare management intervention produced clinically meaningful improvements in pain, with a moderate treatment effect size (0.57), a greater rate of improvement (56% vs. 31%), and a number needed to treat of 4 for pain response. Second, this was accompanied by greater patient satisfaction with pain treatment. Third, although one-third of patients were taking opioid therapy at baseline, few patients in either group were started on opioids or had escalations in their opioid dose. Fourth, patients in the usual care group were more likely to experience worsening of pain by six months compared with those in the intervention group (36% vs. 19%), demonstrating a greater risk of deterioration in the absence of systematic approaches to optimizing pain therapy.”
The report noted that the intervention was effective despite that most trial participants reported pain that had been present for many years involving multiple sites and who had been unsuccessfully treated with numerous analgesics.
“Our results demonstrate both the effectiveness of the telecare as well as the risk of patient deterioration in the absence of systematic approaches to optimizing pain therapy,” Kroenke pointed out. He cautioned, however, that the process requires patience.
He noted that a previous study of depression patients showed rapid initial improvement with telecare while, in the SCOPE study, chronic pain improvement was gradual over the year.
Kroenke said he and his fellow researchers decided to focus on pain for this study because it is “among the most common conditions that comes into clinical practice and, importantly, is among the leading causes of disability and lost word productivity,” adding, “Of these pains, the most common is musculoskeletal pain, which accounts for two-thirds of all patientcomplaints that come in. And by that I mean low back pain, neck pain, arthritis, fibromyalgia, pain in other joints.”
Future research is likely to focus on pain medicine adjustment with Internet-based self-management strategies, he said.
“The bottom line is, I think, that we need to combine pain medications with other kinds of strategies in addition to medicines, and I think we’ll then increase the benefit we’ll obtain,” according to Kroenke.
1Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Bair MJ. Telecare collaborative management of chronic pain in primary care: a randomized clinical trial. JAMA.
2014 Jul 16;312(3):240-8. doi: 10.1001/jama.2014.7689. PubMed PMID: 25027139.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.