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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.
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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.

Last updated on: February 2, 2018
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