Stroke QUERI Project - Evaluation of Stepped Care for Chronic Pain in Iraqi/Afghanistan Veterans

Project Number F4437I funded by HSR&D.
October 1, 2007 - September 30, 2010

Pain is remarkably common and is the most frequent reason patients seek health care. Each year chronic pain plagues over 50 million individuals and one third will experience severe chronic pain at some point in their lives. Chronic musculoskeletal pain is the most common cause of the long-term disability and the related costs in lost productivity are staggering. Despite the prevalence and negative impact, there have been relatively few intervention studies to address chronic pain and none among Operations Iraqi and Enduring Freedom (OIF/OEF) veterans. The absence of studies is concerning because chronic pain may prove to be even more prevalent and disabling in these veterans than for previous combat veterans due to the high combat intensity of the current conflicts. Enormous challenges lie ahead for the VA as OIF/OEF veterans return home and seek care in our facilities for pain, given its prevalence and morbidity and the complexity and cost of managing pain. Adding to the complexity of managing these painful injuries is the high prevalence of psychiatric comorbidity of OIF/OEF veterans.

Chronic pain is complex and requires a multidisciplinary treatment approach. While multidisciplinary pain clinics have been shown to improve pain outcomes, these clinics and services are not widely available. Therefore, research to develop effective approaches to chronic pain management is urgently needed. To address this need, our long term research objective is to demonstrate the effectiveness of multi-modal, multi-disciplinary interventions to determine the best combinations of pharmacological and non-pharmacological treatments for chronic pain. Before these goals can be realized, however, it will be essential to develop and test novel interventions strategies to improve pain care for veterans. Through the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial we aim to develop and test a stepped-care intervention to improve functional and other pain outcomes of OIF/OEF veterans with chronic musculoskeletal pain. Stepped-care involves starting with lower intensity, less costly treatment initially (Step 1) and "stepping up" to more intensive, costly or complex treatment in patients with inadequate response (Step 2). We believe a stepped care intervention directly addresses the R&D goal to challenge existing treatment paradigms.

Our study population will be 240 OIF/OEF active duty service members and veterans with chronic and disabling pain of the spine or extremities. Participants will be recruited from two study sites: the Roudebush VA Medical Center and Walter Reed Army Medical Center. The study design will be a randomized controlled trial. The stepped care approach will involve 12 weeks of optimizing analgesic use coupled with a pain self-management program ( Step 1) followed by 12 weeks of brief cognitive behavioral therapy in participants with inadequate improvement in pain-related disability and pain severity (Step 2). Patients treated in usual care will be the control group. Thus, the primary objective of the ESCAPE trial is to compare the effectiveness of a stepped care intervention vs. usual care in OIF/OEF veterans with chronic and disabling musculoskeletal pain and to evaluate the impact of this intervention on pain-related disability, pain severity, psychological distress, and secondary outcomes.