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.