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Integrated and Comprehensive Pain Management Programs: Effectiveness and Harms
Comparative Effectiveness Review, No. 251
Investigators: Andrea C. Skelly, Ph.D., M.P.H., Roger Chou, M.D., Joseph R. Dettori, Ph.D., M.P.H., M.P.T., Erika D. Brodt, B.S., Andrea Diulio-Nakamura, Ph.D., Kim Mauer, M.D., Rongwei Fu, Ph.D., Yun Yu, M.S., Ngoc Wasson, M.P.H., Shelby Kantner, B.A., and Shay Stabler-Morris, B.A.
Structured Abstract
Objectives:
To evaluate the effectiveness and harms of pain management programs that are based on the biopsychosocial model of care, particularly in the Medicare population.
Data sources:
Electronic databases (Ovid® MEDLINE®, PsycINFO®, CINAHL®, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews) from 1989 to May 24, 2021; reference lists; and a Federal Register notice.
Review methods:
Given lack of consensus on terminology and program definition for pain management, we defined programs as integrated (based in and integrated with primary care) and comprehensive (referral based and separate from primary care) pain management programs (IPMPs and CPMPs). Using predefined criteria and dual review, we selected randomized controlled trials (RCTs) comparing IPMPs and CPMPs with usual care or waitlist, physical activity, pharmacologic therapy, and psychological therapy in patients with complex acute/subacute pain or chronic nonactive cancer pain. Patients needed to have access to medication support/review, psychological support, and physical function support in programs. Meta-analyses were conducted to improve estimate precision. We classified the magnitude of effects as small, moderate, or large based on predefined criteria. Strength of evidence (SOE) was assessed for the primary outcomes of pain, function, and change in opioid use.
Results:
We included 57 RCTs; 8 evaluated IPMPs and 49 evaluated CPMPs. Compared with usual care or waitlist, IPMPs were associated with small improvements in pain in the short and intermediate term (SOE: low) and in function in the short term (SOE: moderate), but there were no clear differences at other time points. CPMPs were associated with small improvements in pain immediately postintervention (SOE: moderate) but no differences in the short, intermediate, and long term (SOE: low); for function, improvements were moderate immediately postintervention and in the short term; there were no differences in the intermediate or long term (SOE: low at all time points). CPMPs were associated with small to moderate improvements in function and pain versus pharmacologic treatment alone at multiple time frames (SOE: moderate for function intermediate term; low for pain and function at all other times), and with small improvements in function but no improvements in pain in the short term when compared with physical activity alone (SOE: moderate). There were no differences between CPMPs and psychological therapy alone at any time (SOE: low). Serious harms were not reported, although evidence on harms was insufficient. The mean age was 57 years across IPMP RCTs and 45 years across CPMP RCTs. None of the trials specifically enrolled Medicare beneficiaries. Evidence on factors related to program structure, delivery, coordination, and components that may impact outcomes is sparse and there was substantial variability across studies on these factors.
Conclusions:
IPMPs and CPMPs may provide small to moderate improvements in function and small improvements in pain in patients with chronic pain compared with usual care. Formal pain management programs have not been widely implemented in the United States for general populations or the Medicare population. To the extent that programs are tailored to patients’ needs, our findings are potentially applicable to the Medicare population. Programs that address a range of biopsychosocial aspects of pain, tailor components to patient need, and coordinate care may be of particular importance in this population.
Contents
- Preface
- Investigator Affiliations
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Evidence Summary
- Introduction
- Methods
- Results
- Discussion
- References
- Abbreviations and Acronyms
- Appendixes
- Appendix A. Methods
- Appendix B. Results Overview
- Appendix C. Contextual Questions
- Appendix D. Included Studies List
- Appendix E. Evidence Tables
- Appendix F. Risk of Bias Assessments
- Appendix G. Strength of Evidence
- Appendix H. Excluded Studies List
- Appendix I. Forest Plots
- Appendix J. Definitions of Magnitudes of Effect
- Appendix K. Appendix References
Suggested citation:
Skelly AC, Chou R, Dettori JR, Brodt ED, Diulio-Nakamura A, Mauer K, Fu R, Yu Y, Wasson N, Kantner S, Stabler-Morris S. Integrated and Comprehensive Pain Management Programs: Effectiveness and Harms. Comparative Effectiveness Review No. 251. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.) AHRQ Publication No. 22-EHC002. Rockville, MD: Agency for Healthcare Research and Quality; October 2021. DOI: https://doi.org/10.23970/AHRQEPCCER251. Posted final reports are located on the Effective Health Care Program search page.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00006). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment: This work was based on an evidence report, Integrated and Comprehensive Pain Management Programs: Effectiveness and Harms, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ).
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