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13 Articles in Volume 18, Issue #1
Applying a Collaborative Care Model to the Treatment of Chronic Pain and Depression
Assessing the Pain Triangle
Emerging Technologies in Rehabilitation Medicine
Gaming as a Tool for Pain Relief
Honoring Dr. Forest Tennant’s 50-Plus Years in Pain Management
Is There a Chronic Pain Personality Profile?
Managing Musculoskeletal Pain in Endurance Athletes
Managing Perioperative Pain
Nonparenteral Oxytocin, Erythromelalgia...Letters from the Minds of Peers and Patients
OSKA PEMF Pain Relief Device: A Mini Review Trial
Patient Communication & Opioid Prescribing in the New Year
What Opioid Shopping Means for Pain Practitioners
Would Patients Benefit from a Glucosamine/Chondroitin Supplement to Manage Knee Osteoarthritis Pain?

Applying a Collaborative Care Model to the Treatment of Chronic Pain and Depression

In this Q&A, Dawn Ehde, PhD, of MS Care at UW School of Medicine, describes how her team’s study may have strategic application in managing comorbid chronic pain conditions.

About the Model

MS Care is a program of the University of Washington School of Medicine, where the collaborative care model was founded more than 20 years ago. It aims to improve delivery and utilization of evidence-based treatments for chronic pain and depression in multiple sclerosis (MS) patients through integrative care. The model aims to enhance the existing comprehensive care found in MS specialty care centers through the use of a care manager who represents a team of experts including the patient’s MS provider and specialists. The patient is placed at the center of care, which also involves telehealth, systematic tracking, and other systems-level changes. Established in 2013, the MS Care program has been part of a clinical trial studying the effect of collaborative care on comorbid pain and depression, with the most recent results published in January 2018.1,2

Dawn Ehde, PhD, a clinical psychologist and professor of rehabilitation medicine at the University of Washington School of Medicine—the birthplace of the collaborative care model—describes how her team’s study of the growing integrative approach in patients with multiple sclerosis and depression may have strategic application in managing other comorbid chronic pain conditions.

 

Can you provide a brief overview of your trial findings to date?

Enrollment in our current study1,2 began in May 2014, and we collected our final data in March 2017. We are actively conducting data analyses on the 10-month randomized, controlled trial involving 195 participants, and writing up the findings for scientific publication. A few results stand out thus far:

  • MS Care improved pain, depression, and other important outcomes. Patients participating in the intervention had significantly better outcomes than those who received usual care. For example, at post-treatment (four months) and six-month follow-up, participants randomly assigned to MS Care reported statistically significant decreases in pain interference, pain intensity, depression severity, fatigue, and disability due to pain/depression as compared with those assigned to usual care.
  • Use of the telephone improved access and adherence to care. Participants were offered the opportunity to receive their care sessions in person or by scheduled telephone appointments. When given this choice, most —74%—of the sessions occurred by phone. Some sessions occurred all by phone, some all in person, and some were a mixture. We also found that of those assigned to MS Care, 90% completed their treatment sessions. This result, to date, adds to existing evidence3,4 that the telephone is an effective, simple method for increasing access to care for those patients who may otherwise find in-person care inaccessible.
  • MS Care improved patient satisfaction with care. Despite already reporting a high level of satisfaction with their healthcare at the start of the study, after the intervention, MS Care participants rated their satisfaction with their pain and depression care, general MS care, and overall healthcare significantly higher than patients who were randomized to usual care.

    How do you envision these results applying to the practice of treating patients with chronic pain due to other medical conditions, beyond MS?

    Over the past few years, collaborative care for pain has been examined in primary care settings—for example, by Kroenke et al and Dobscha et al.5,6 Like these other collaborative care interventions, MS Care utilized a care manager to monitor, coordinate, and intensify care and to deliver brief psychoeducational interventions. What distinguished this type of collaborative care is that care managers (licensed social workers, in this case) emphasized teaching patients evidence-
    based skills for self-managing pain and depression; other studies of pain in primary care have appeared to utilize less intensive behavioral interventions.

    Many patients with MS have demonstrated an eagerness to use nonpharmacologic approaches to pain, including cognitive behavioral techniques, mindfulness-based strategies, and physical activity. It may be presumed that patients with other chronic pain conditions may have the same willingness. Thus, our research team offered patients a menu of pain and depression self-management strategies to learn from the care manager, in addition to the other aspects of care common in a collaborative care setting.

    Further, we added to the collaborative care consultant/supervisor team a psychologist with expertise in rehabilitation and pain psychology to provide guidance on delivering the behavioral interventions. Other collaborative care programs targeting pain may want to consider incorporating the expertise of a psychologist to offer additional evidence-based behavioral treatments, such as mindfulness or cognitive behavioral therapy.

    Why is treating depression in patients with chronic pain so crucial?

    Depressive symptoms and chronic pain are highly comorbid: co-occurrence rates range from 30 to 50% across different populations. They have a shared neurobiology, cognitive influences, and behavioral impacts. There is good evidence that their relationship is bidirectional and additive: the presence of both is associated with higher disability, and the presence of depression reduces the effectiveness of pain treatment, and vice versa. See, for example, studies by Kroekne et al, Damush et al, DeVeaugh-Geiss et al, and Goesling et al.7-10 Thus, we believe that treating both conditions concurrently will improve outcomes more than only treating one.

    What strategies might a provider team use to make communication most effective?

    In our model, a care manager facilitated most of the communication. For example, if the consultants recommended a medication change, the care manager communicated the change to the prescribing provider, whether it be the patient’s neurologist in the specialty care center, a nurse practitioner, or the primary care provider in the larger system or community. As needed, the consultants would communicate directly with the prescribing provider. Similarly, the care manager communicated and coordinated with any mental health providers involved in the patient’s care.

    The care manager was also responsible for collecting medication information, which the collaborative care team reviewed in weekly panel meetings. When medication discrepancies or concerns arose, they were quickly identified and handled by the team in collaboration with the prescribing providers. Although we have just begun to look at our medication data, this practice has the potential to reduce adverse drug interaction, potential overdose, and use of ineffective medications.

    Overall, we do not recommend a particular communication method other than that the care manager communicate via providers’ preferred methods, which may vary considerably. The care manager may also be tasked with documenting communications, recommendations, care plans, and progress updates via an electronic medical record.

    Can you describe the patient’s role in the collaborative care approach?

    As the person who does the “heavy lifting” when it comes to managing pain, mood, and overall health, the patient was at the center of our model. They were part of determining next steps in the treatment plan, including what communications were needed among the care manager and providers. Patients appeared to appreciate having multiple providers and readily accepted the model, including the care manager and the consultant team (whom they typically did not meet).

    In clinic visits, the neurologists described learning directly from their patients about what they were doing to manage their pain. The providers, in turn, reinforced the patient’s self-management strategies and built upon them as indicated. There was no trepidation expressed among providers regarding this team approach.

    What might the integrative care model offer in terms of cost-effectiveness and patient follow-through?

    A core strength of collaborative care is its use of care managers, consultants, and patient registries for tracking patients, plans, and outcomes. These components make it difficult for patients to “fall through the cracks.” The care manager actively reaches out to patients who may not be adhering to care sessions or other aspects of the treatment plan. Because our model integrated behavioral strategies, it also reduced the need for patients to go outside of the system or clinic to see a mental health provider, few of whom may have expertise in multiple sclerosis and/or behavioral treatment of chronic pain. Thus, the patient was able to benefit from the expertise of the collaborative team’s care managers and psychology consultants, who do hold this expertise.

    The use of the telephone to deliver care, based on patient preference, also made care more accessible. This approach was particularly important for MS patients, many of whom experience debilitating fatigue and/or face transportation barriers to obtaining care. We suspect that patients may have been more willing to participate in behavioral care delivered via MS Care, as the care was viewed as part of the overall approach and potentially less stigmatizing. We indeed found excellent adherence within our trial participants.

    In terms of expense, collaborative care typically costs more to set up initially (eg, hiring a care manager and paying for consultants) and has some ongoing associated costs. However, progress is being made for addressing costs through the inclusion of behavioral health in accountable care organizations and the recent addition of CPT codes for integrated care. Evidence has suggested that collaborative care is a cost-
    effective method for treating depression in primary care.11 We suspect the same may be true for MS Care, although future research is needed to test this hypothesis.

    In pain management, substance use must be monitored. How might integrative strategies assist in this effort?

    Collaborative care and other strategies that improve pain and depression management have considerable potential for preventing or reducing inappropriate medication misuse and dependence. This view is consistent with the recent National Academies of Sciences, Engineering, and Medicine Consensus Study Report,12 which highlighted the importance of nonpharmacological treatments for pain, including cognitive behavior therapy, mindfulness meditation, and physical therapy/exercise, as well as stepped care (which collaborative care uses), as important tools in managing pain and preventing potential medication misuse. Collaborative care also works to identify patients at risk of or having opioid misuse or dependence, and facilitates referrals to appropriate addiction care.

    You have been working on collaborative care models for approximately two decades. Why is this work is so important to the healthcare industry going forward?

    For years, healthcare providers have had effective treatments for pain and depression, including cognitive behavioral and self-management tools and interventions. Our industry needs to improve upon these treatments by developing more efficacious models or combinations of treatments, and some of our research team’s work is tackling these challenges.

    Early in my career, I noticed that too few individuals with chronic pain and neurologic conditions such as MS were aware of or accessing existing, potentially helpful treatments, especially behavioral ones. Some of this under-utilization is likely due to our reliance on traditional models of care in which treatments, particularly behavioral ones, are delivered face-to-face, one-on-one, in 45 to 60 minute increments, by an expert (thus rare) clinician. My work, therefore, has focused on strategies for bridging these gaps in care so that more patients may benefit from evidence-based pain and depression management strategies. Our team is focused on alternative models, such as MS Care, and using the telephone and other technologies to make treatments not only more accessible, but also more integrated into healthcare.

     

    Expert Bio: Dawn M. Ehde, PhD, is the principal investigator on the randomized controlled MS Care Study, and serves as a clinical psychologist and professor of rehabilitation medicine in the Division of Clinical and Neuropsychology at the University of Washington (UW) School of Medicine. She earned her doctoral degree in clinical psychology from the University of North Dakota and completed her residency, a clinical postdoctoral fellowship, and research postdoctoral fellowship at the University of Washington, with an emphasis on rehabilitation psychology, neuropsychology, and research. Dr. Ehde has been on the faculty of UW Medicine in Seattle since 1994. She is a fellow of the American Psychological Association and editor of Rehabilitation Psychology.

Last updated on: February 2, 2018
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