QUERI – Quality Enhancement Research Initiative

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QUERI Assesses Biopsychosocial Approach to Pain Management

Last year, the Centers for Disease Control (CDC) recommended a biopsychosocial approach to pain management that discourages opioid use and, instead, promotes exercise therapy, cognitive behavioral therapy, and non-opioid medications as first-line patient-centered treatments. This multi-modal strategy is best delivered by an interdisciplinary team. However, in the private sector interdisciplinary pain management services are challenging to deliver; for example, they're not typically available in primary care and not easily reimbursed. In contrast, in a fully integrated healthcare system such as the Veterans Health Administration (VHA), interdisciplinary pain management clinics are already embedded in primary care,1,2 but have not been well-studied. To fill this research gap, HSR&D is supporting a mixed-methods quality improvement study of the Integrated Pain Team clinic in the San Francisco VA Health Care System (SFVAHCS), as part of the Measurement Science QUERI.

The SFVAHCS Integrated Pain Team (IPT) clinic was established in July 2015 within primary care. The IPT clinic provides interdisciplinary, biopsychosocial pain care that also addresses psychological comorbidities, such as Veterans with both post-traumatic stress disorder (PTSD) and opioid use disorder. The interdisciplinary IPT clinic integrates and co-locates pain-trained primary care providers (PCPs) with a psychologist and pharmacist, along with expedited access to physical and recreational therapy. Other PCPs refer patients with complex chronic pain, and IPT providers then collaborate with the patient and referring PCP to develop a multi-modal holistic pain care plan that emphasizes exercise, behavioral interventions, and integrative modalities, while decreasing reliance on opioids. When the patient is discharged, IPT providers transition the patient back to the referring PCP. In addition, the IPT clinic utilizes video telehealth technology to reach Veterans who reside in rural areas.

Preliminarily, Measurement Science QUERI examined 162 Veterans: 81 enrolled in the IPT clinic compared to 81 matched control patients who were seen in usual primary care during the same time-period and followed for 90 days. All patients had chronic pain, were prescribed opioids, and were matched on age, sex, number and type of psychiatric diagnoses, and baseline daily opioid dose. QUERI investigators found that the mean daily opioid dose decreased by 41 mg in the IPT group after 90 days, while reduction among controls was only 25 mg. In addition, twice as many patients in the IPT clinic compared to controls reduced their daily opioid dose by 50% or more, representing a 2.6-fold increase in the odds of a > 50% reduction in daily opioid use.

These data suggest that interdisciplinary team-based pain care may be superior to usual primary care in decreasing reliance on opioids for pain management, which, in turn, may reduce the risk for serious opioid-related harms. This interdisciplinary pain care model, while relatively easy to assemble in a fully integrated system like VA, is more costly and far less feasible within a more fragmented private sector healthcare system. Nevertheless, with recent proposals to channel Veterans' healthcare to the private sector,3 integrated care models like ITP may be in jeopardy. Additional QI data, including forthcoming qualitative data from clinic stakeholders, will guide QUERI investigators in helping to further refine the IPT, such that it best meets the needs of some of the more vulnerable VA patients.

For more information about this project, please contact Karen Seal, MD, at Karen.Seal@va.gov.

References

1. Dorflinger LM, Ruser C, Sellinger J, et al. Integrating interdisciplinary pain management into primary care: development and implementation of a novel clinical program. Pain Medicine. December 2014;15(12):2046-2054.

2. Wiedemer NL, Harden PS, Arndt IO, and Gallagher RM. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Medicine. October-November, 2007;8(7):573-584.

3. Final Report of the Commission on Care. June 30, 2016. Commission on Care. 1575 I Street, NW. Washington, DC 20005. (Accessed January 4, 2017).

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