Evaluation of Stepped Care for Chronic Pain (ESCAPE) in veterans of the iraq and afghanistan conflicts a randomized clinical trial

Matthew Bair, Dennis Ang, Jingwei Wu, Samantha D. Outcalt, Christy Sargent, Carol Kempf, Amanda Froman, Arlene A. Schmid, Teresa Damush, Zhangsheng Yu, Louanne W. Davis, Kurt Kroenke

Research output: Contribution to journalArticle

38 Citations (Scopus)

Abstract

Importance Despite the prevalence and the functional, psychological, and economic impact of chronic pain, few intervention studies of treatment of chronic pain in veterans have been performed. Objective To determine whether a stepped-care intervention is more effective than usual care, as hypothesized, in reducing pain-related disability, pain interference, and pain severity. Design, Setting, and Participants We performed a randomized clinical trial comparing stepped care with usual care for chronic pain.We enrolled 241 veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn with chronic (>3 months) and disabling (Roland Morris Disability Scale score,≥7) musculoskeletal pain of the cervical or lumbar spine or extremities (shoulders, knees, and hips) in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial from December 20, 2007, through June 30, 2011. The 9-month follow-up was completed by April 2012. Patients received treatment at a postdeployment clinic and 5 general medicine clinics at a Veterans Affairs medical center. Interventions Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm coupled with pain self-management strategies; step 2, 12 weeks of cognitive behavioral therapy. All intervention aspects were delivered by nurse care managers. Main Outcomes and Measures Pain-related disability (Roland Morris Disability Scale), pain interference (Brief Pain Inventory), and pain severity (Graded Chronic Pain Scale). Results The primary analysis included 121 patients receiving the stepped-care intervention and 120 patients receiving usual care. At 9 months, the mean decrease from baseline in the Roland Morris Disability Scale score was 1.7 (95%CI,-2.6 to-0.9) points in the usual care group and 3.7 (95%CI,-4.5 to-2.8) points in the intervention group (between-group difference,-1.9 [95%CI,-3.2 to-0.7] points; P =.002). The mean decrease from baseline in the Pain Interference subscale score of the Brief Pain Inventory was 0.9 points in the usual care group and 1.7 points in the intervention group (between-group difference,-0.8 [95%CI,-1.3 to-0.3] points; P =.003). The Graded Chronic Pain Scale severity score was reduced by 4.5 points in the usual care group and 11.1 points in the intervention group (between-group difference,-6.6 [95%CI,-10.5 to-2.7] points; P =.001). Conclusions and Relevance A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in veterans with chronic musculoskeletal pain.

Original languageEnglish
Pages (from-to)682-689
Number of pages8
JournalJAMA Internal Medicine
Volume175
Issue number5
DOIs
StatePublished - May 1 2015

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Afghanistan
Iraq
Veterans
Chronic Pain
Randomized Controlled Trials
Pain
2003-2011 Iraq War
Musculoskeletal Pain
Cognitive Therapy
Self Care
Analgesics
Conflict (Psychology)
Afghan Campaign 2001-
Equipment and Supplies
Pain Management
Hip
Knee
Spine
Therapeutics

ASJC Scopus subject areas

  • Internal Medicine
  • Medicine(all)

Cite this

Evaluation of Stepped Care for Chronic Pain (ESCAPE) in veterans of the iraq and afghanistan conflicts a randomized clinical trial. / Bair, Matthew; Ang, Dennis; Wu, Jingwei; Outcalt, Samantha D.; Sargent, Christy; Kempf, Carol; Froman, Amanda; Schmid, Arlene A.; Damush, Teresa; Yu, Zhangsheng; Davis, Louanne W.; Kroenke, Kurt.

In: JAMA Internal Medicine, Vol. 175, No. 5, 01.05.2015, p. 682-689.

Research output: Contribution to journalArticle

Bair, Matthew ; Ang, Dennis ; Wu, Jingwei ; Outcalt, Samantha D. ; Sargent, Christy ; Kempf, Carol ; Froman, Amanda ; Schmid, Arlene A. ; Damush, Teresa ; Yu, Zhangsheng ; Davis, Louanne W. ; Kroenke, Kurt. / Evaluation of Stepped Care for Chronic Pain (ESCAPE) in veterans of the iraq and afghanistan conflicts a randomized clinical trial. In: JAMA Internal Medicine. 2015 ; Vol. 175, No. 5. pp. 682-689.
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abstract = "Importance Despite the prevalence and the functional, psychological, and economic impact of chronic pain, few intervention studies of treatment of chronic pain in veterans have been performed. Objective To determine whether a stepped-care intervention is more effective than usual care, as hypothesized, in reducing pain-related disability, pain interference, and pain severity. Design, Setting, and Participants We performed a randomized clinical trial comparing stepped care with usual care for chronic pain.We enrolled 241 veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn with chronic (>3 months) and disabling (Roland Morris Disability Scale score,≥7) musculoskeletal pain of the cervical or lumbar spine or extremities (shoulders, knees, and hips) in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial from December 20, 2007, through June 30, 2011. The 9-month follow-up was completed by April 2012. Patients received treatment at a postdeployment clinic and 5 general medicine clinics at a Veterans Affairs medical center. Interventions Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm coupled with pain self-management strategies; step 2, 12 weeks of cognitive behavioral therapy. All intervention aspects were delivered by nurse care managers. Main Outcomes and Measures Pain-related disability (Roland Morris Disability Scale), pain interference (Brief Pain Inventory), and pain severity (Graded Chronic Pain Scale). Results The primary analysis included 121 patients receiving the stepped-care intervention and 120 patients receiving usual care. At 9 months, the mean decrease from baseline in the Roland Morris Disability Scale score was 1.7 (95{\%}CI,-2.6 to-0.9) points in the usual care group and 3.7 (95{\%}CI,-4.5 to-2.8) points in the intervention group (between-group difference,-1.9 [95{\%}CI,-3.2 to-0.7] points; P =.002). The mean decrease from baseline in the Pain Interference subscale score of the Brief Pain Inventory was 0.9 points in the usual care group and 1.7 points in the intervention group (between-group difference,-0.8 [95{\%}CI,-1.3 to-0.3] points; P =.003). The Graded Chronic Pain Scale severity score was reduced by 4.5 points in the usual care group and 11.1 points in the intervention group (between-group difference,-6.6 [95{\%}CI,-10.5 to-2.7] points; P =.001). Conclusions and Relevance A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in veterans with chronic musculoskeletal pain.",
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AU - Sargent, Christy

AU - Kempf, Carol

AU - Froman, Amanda

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N2 - Importance Despite the prevalence and the functional, psychological, and economic impact of chronic pain, few intervention studies of treatment of chronic pain in veterans have been performed. Objective To determine whether a stepped-care intervention is more effective than usual care, as hypothesized, in reducing pain-related disability, pain interference, and pain severity. Design, Setting, and Participants We performed a randomized clinical trial comparing stepped care with usual care for chronic pain.We enrolled 241 veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn with chronic (>3 months) and disabling (Roland Morris Disability Scale score,≥7) musculoskeletal pain of the cervical or lumbar spine or extremities (shoulders, knees, and hips) in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial from December 20, 2007, through June 30, 2011. The 9-month follow-up was completed by April 2012. Patients received treatment at a postdeployment clinic and 5 general medicine clinics at a Veterans Affairs medical center. Interventions Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm coupled with pain self-management strategies; step 2, 12 weeks of cognitive behavioral therapy. All intervention aspects were delivered by nurse care managers. Main Outcomes and Measures Pain-related disability (Roland Morris Disability Scale), pain interference (Brief Pain Inventory), and pain severity (Graded Chronic Pain Scale). Results The primary analysis included 121 patients receiving the stepped-care intervention and 120 patients receiving usual care. At 9 months, the mean decrease from baseline in the Roland Morris Disability Scale score was 1.7 (95%CI,-2.6 to-0.9) points in the usual care group and 3.7 (95%CI,-4.5 to-2.8) points in the intervention group (between-group difference,-1.9 [95%CI,-3.2 to-0.7] points; P =.002). The mean decrease from baseline in the Pain Interference subscale score of the Brief Pain Inventory was 0.9 points in the usual care group and 1.7 points in the intervention group (between-group difference,-0.8 [95%CI,-1.3 to-0.3] points; P =.003). The Graded Chronic Pain Scale severity score was reduced by 4.5 points in the usual care group and 11.1 points in the intervention group (between-group difference,-6.6 [95%CI,-10.5 to-2.7] points; P =.001). Conclusions and Relevance A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in veterans with chronic musculoskeletal pain.

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