Stepped-care management useful for chronic pain treatment in veterans (ESCAPE Trial)

1. Stepped-care intervention (analgesia with self-management strategies followed by cognitive behavioral therapy) was associated with decreased pain-related disability, interference, and severity in veterans with chronic pain.

Evidence Rating Level: 1 (Excellent)

Study Rundown: With the high prevalence of chronic pain syndromes in American veterans, it has become increasingly important to determine an effective means of management. Both analgesia and cognitive behavioural therapy (CBT) have been shown to be effective in different pain syndromes previously. However, no studies have examined a stepped-treatment intervention in the veteran population. This randomized controlled trial examined whether a 2-step intervention, consisting of 12 weeks of analgesic therapy coupled with self-management strategies followed by 12-weeks of CBT, was more effective than usual care in decreasing pain-related disability, interference and severity.

This study found that veterans randomized to the stepped-care intervention resulted in statistically significant reductions in pain-related disability, pain interference and pain severity as compared to patients in usual care. Strengths of the study include using validated pain scales for outcome measurement as well as use of intention-to-treat analysis. However, limitations include being a single-blinded, single-centred study with a large number of patient exclusions prior to randomization.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Depression and Pain Comorbidity: A Literature Review

In-Depth [randomized controlled trial]: This randomized controlled trial recruited participants from post-deployment and general medicine clinics in a VA Medical Centre from December 2007 to June 2011. Participants were included if they were veterans from the Afghanistan and Iraq conflicts and had self-reported chronic pain for more than 3 months that was moderately disabling. They were randomized in groups of 8 to either stepped-care or usual care. Stepped-care included 12 weeks of analgesic treatment with optimization according to an algorithm coupled with self-management strategies, followed by 12 weeks of CBT. Participants in the usual care arm received education and ‘usual’ pharmacological and non-pharmacological treatment from their physicians. Data on pain-disability, interference and severity were collected at 3, 6 and 9 months post-randomization using three validated assessment scales. Data was analyzed using an intention-to-treat protocol.

Of the 659 patients assessed for this study, 121 were randomized to the stepped-care intervention and 120 were randomized to usual care. At 9 months, there was a decrease in pain-related disability (between-group difference, -1.9, 95%CI -3.2 to -0.7 points, P=0.002), pain interference (between-group difference, -0.8, 95%CI -1.3 to -0.3 points, P=0.003), and pain severity (between-group difference, -6.6, 95%CI -10.5 to -2.7 points, P=0.001) in the stepped-care intervention group as compared to those undergoing usual care.

Image: PD

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