Telecare: Just What the Doctor Ordered for Chronic Pain?

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Written By

Nina Cimino, Pharm.D.
Leah Sera, Pharm.D., BCPS

Reviewed By

Suzanne A. Nesbit, Pharm.D., BCPS, CPE
Sarah Onofrio, Pharm.D.
Mitchell Nazario, Pharm.D.
Sandra DiScala, Pharm.D., BCPS

Citation

Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Blaire MJ. Telecare collaborative management of chronic pain in primary care. JAMA. 2014; 312: 240-48

Telecare — providing care to patients using a variety of communication technologies — has been touted as a win-win strategy for providers and patients that improves clinical outcomes at a lower cost. Systematic reviews have documented the benefits of telecare in several populations including patients with pulmonary disease, diabetes, heart disease, and hypertension.1-4  Like other chronic illnesses, chronic musculoskeletal pain is common, difficult to manage, and costly. According to the American Academy of Pain Medicine, over 50% of the American workforce reports experiencing musculoskeletal pain in the previous two weeks.5. Among patients receiving prescription medications for pain, less than two-thirds consider them effective.5  The economic burden of musculoskeletal pain is substantial!  Lost productivity alone is estimated to cost our economy $60 billion each year.5

The purpose of the Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was to determine whether a telephone- and internet-based patient management model of care for musculoskeletal pain is more effective than usual care.6  SCOPE was a 12-month, randomized, controlled trial that recruited patients from 5 primary care clinics in Veterans Affairs (VA) Medical Centers in the Midwest.  Patients were eligible to take part in the study if they were aged 18-65 years and had musculoskeletal pain that was moderately severe (Brief Pain Inventory score >5) and persistent (>3 months). Patients were excluded from the study if they had a psychiatric illness, cognitive impairment, ongoing illicit drug use disorder, or life expectancy of less than 12 months. Eligible patients were randomized and stratified by opioid use at baseline.

The primary outcome of SCOPE was the mean between-group difference in Brief Pain Inventory (BPI) score over the 12-month study period. The BPI rates pain severity (on a 0-10 scale) for current, best, worst, and average pain in the previous week.  The BPI also asks patients about the interference of pain (on a 0-10 scale) on mood, work, general activity, walking ability, interpersonal relations, sleep, and enjoyment of life.  A 1-point change in BPI score is considered clinically important. Secondary pain outcomes included between-group differences in response rates (defined as a 30% decrease or more in BPI score from baseline), mean BPI interference and severity scores, and retrospective patient perception of change in pain from baseline to 6 months. Outcome assessments were conducted at baseline, 1, 3, 6, and 12 months by interviewers blinded to treatment arm.

Patients in the intervention group (n=124) received automated symptom monitoring (ASM) via either interactive voice recorded (IVR) phone calls or the Internet.  The ASM tool queried the patient about 15 items, including questions from several validated instruments: pain, enjoyment of life, and general activity (PEG); General Anxiety Disorder (GAD-2): and the Patient Health Questionnaire (PHQ-2).  Four questions ask about ability to perform activities, effectiveness of pain medications, and change in pain. Three questions ask about side effects, adherence to medications, and whether medication changes were desired.  Lastly, patients could request a phone call from the nurse case manager. Patients who reported less than 30% improvement in PEG pain score, global improvement less than moderate, or a desire for medication change were assessed by a nurse for adjustment in analgesic therapy. The algorithm for pain management during the study included acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, cyclobenzaprine, gabapentinoids, tramadol, topical analgesics, and opioids. In the usual care arm (n=126), patients’ musculoskeletal pain was managed by their primary care physician.

Baseline characteristics were similar between groups with an average age of 55 years. The majority of participants in both groups were white men.  The average baseline BPI score was 5.2 (range 0-10).

Over the 12-month study period, the average total BPI score improved incrementally and substantially more in the intervention group (Table 1). Moreover, total BPI, BPI severity, and BPI interference scores were significantly better in the telecare group when compared to the patients in the usual care group even after adjusting for patient age, sex, race, socioeconomic status, education, clinic, or mode of monitoring (IVR or internet). Patients in the intervention arm were also more likely to report a 30% reduction in BPI score at 12 months and to report global improvement in pain at 6 months. The number needed to treat for global pain improvement at 6 months was 4 (95% CI; 2.9 to 6.2).

Table 1. Changes in Brief Pain Inventory (BPI) Score
Total pain score (score range 0-10), mean (SD)

 

Intervention
 (n=124)

Control
(n=126)

Time-specific between-group difference (95% CI)

Overall
P value

Baseline

5.31 (1.81)

5.12 (1.80)

0.19 (-0.26 to 0.64)

 

 

<0.001

1 month

4.72 (1.97)

4.75 (1.97)

-0.02 (-0.50 to 0.46)

3 months

4.29 (2.15)

4.79 (1.95)

-0.50 (-1.05 to 0.02)

6 months

4.12 (2.43)

4.47 (2.17)

-0.34 (-0.93 to 0.23)

12 months

3.57 (2.22)

4.59 (2.13)

-1.02 (-1.58 to -0.47)

 

Although the number of analgesics used was similar at baseline, patients in the intervention group were prescribed significantly more analgesics during the study than the control group patients (mean 3.0 vs 1.6; P<0.001). However, there was no difference in opioid use at baseline or during the study.  In addition, health care utilization, including outpatient visits, hospitalizations, and emergency room visits, were not different.

The improvements in pain achieved in the SCOPE study are similar to those observed in two previous studies that delivered care to patients in primary care settings.7,8  Telecare models for pain management have also been evaluated in patients with osteoarthritis as well as patients with concomitant depression and cancer.9,10 While telecare resulted in a significant improvement in osteoarthritis pain when compared to a general health education intervention, it was no better than usual care in one study.9  In another study, in patients with both pain and depression treated in an oncology practice, a telecare intervention led to significant improvements in pain after 1 year when compared to usual care.10

The SCOPE study was well designed and documents clinically important improvements in pain using a telephone-based pain management model of care.  However, it is somewhat disappointing that the use of opioids and acute care services (emergency department visits and hospitalizations) were unchanged.  There are several factors that limit the study’s external validity. Most importantly, because this study was conducted in the VA system, few women and minorities were enrolled.  Moreover, most study participants reported some higher education and few financial barriers.  It’s unclear how well this program would work in an environment where patients were less educated and lacked financial resources. Non-pharmacologic pain management strategies— such as exercise, physical therapy, and relaxation — were not employed in this study.   But these strategies can clearly play an important role in the management of chronic pain. Finally, this study did not include an analysis of or discussion regarding the cost of this care model.

Notably, none of the telecare chronic pain management studies published to date have included a pharmacist in the delivery model.  However, telecare delivered by pharmacists has been evaluated in one program targeted at patients with uncontrolled hypertension.11  This telecare program was conducted in an integrated health system where pharmacists provided patient education and utilized collaborative practice agreements to make drug therapy adjustments.  Patients randomized to the telecare group also used home blood pressure monitors and transmitted at least six blood pressure readings per week to the pharmacist for review. Significantly more patients achieved their blood pressure goal in the telecare group when compared to patients in the usual care group. Patients in the intervention group also showed improved adherence and self-efficacy compared to patients receiving usual care.

We believe pharmacists are uniquely qualified to provide telecare to patients with chronic pain. Pharmacists have the expertise and clinical training necessary to help patients make the best use their medications. Pharmacists can differentiate between different types of pain (i.e., neuropathic vs. nociceptive) in order to recommend appropriate analgesic therapy.  Moreover they have the training to identify medication-related problems that may impact pain management such as adherence issues, drug-drug interactions, and adverse effects.

The SCOPE study confirms that telecare works, even in the setting of chronic pain management.  SCOPE is among the largest and best-conducted telecare studies to date.  Given these positive findings and the strength of the evidence, should telecare become the preferred care delivery model?  What do you think?