Stories

New Clinical Trial Seeks to Improve Care for Chronic Pain

By Jill Pope, Communications Lead

In September, CHR launched a four-year clinical trial that seeks to improve care for patients with high-impact chronic pain. CHR Distinguished Investigator Lynn DeBar, PhD, is leading the study, along with Nicole Cook, PhD and Rachel Gold, PhD, both investigators at OCHIN.

Chronic pain affects about 24% of U.S. adults, and is the most common reason adults seek medical care. High-impact chronic pain, defined as pain that lasts for three months or longer and that substantially limits life or work activities, affects 8.5% of adults, or about 1 in 12.

The new clinical trial is funded through the National Institute of Health’s HEAL Initiative, a federal effort to prevent and treat opioid misuse and addiction and offer alternative treatments for chronic pain. Recent evidence shows that long-term treatment of chronic pain with opioids carries considerable risk. Current guidelines recommend using safer medications along with complementary approaches such as physical therapy, acupuncture, chiropractic treatment, yoga, massage, and cognitive behavioral therapy. Research has shown that integrated pain management (IPM), which combines these approaches to treat the whole person, can be effective at improving both pain and functioning.

With the variety of providers that may be involved, delivering IPM will require care coordination, which the Agency for Health Care Research and Quality defines as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care.”

Health care providers with robust care coordination systems already in place may be well prepared to offer their patients IPM. However, Community Health Centers (CHCs), which serve patients who are uninsured or publicly insured, may lack the tools and staff to track referrals to external providers and maintain ongoing communication with them. For CHCs, offering IPM to patients may require new tools, staffing, and workflows.

DeBar’s new clinical trial builds on a previous PCORI-sponsored study called Back on Track, in which she and colleagues found that increased Medicaid coverage for non-drug therapies—counseling, physical therapy, acupuncture, chiropractic care, yoga, and massage—led to greater use of these services, with positive impacts on patients’ pain. Through interviews with primary care clinicians and staff, external service providers, and patients, the study also identified challenges with delivering effective chronic pain care in CHCs, including the need for new tools in the electronic health record (EHR), and for care coordination.

In the current study, Coordinated Care Pain Management Technology Implementation (CARNATION), DeBar and her team will provide tools and support to enable CHCs to deliver coordinated pain care. The study will test new EHR tools at clinics within the OCHIN network, support clinics with implementing the tools, and test how this support impacts care delivery. The tools include (1) a patient-reported pain assessment, (2) a SmartSet that supports primary care providers by grouping orders and referrals for pain management, and (3) a care coordination module tailored to track delivery of pain services outside of CHCs. The study will also support in-clinic care coordinators.

The new trial plans to enroll 20 clinics. At the start of the trial, the EHR tools will be available to all clinics; however, ten clinics will be assigned to receive early support with implementing the tools (intervention clinics), and ten will be assigned to receive delayed support (control clinics).

The study will gather health record data from patients at the clinics, and interview patients to learn about their experiences with care coordination. The team will then analyze this data to measure the impact the intervention has on delivery of coordinated pain care. They will also examine whether patients receiving coordinated pain care see improvements in their pain.

DeBar has led two recent studies that tested new approaches to chronic pain care and found them to be effective, including one that studied acupuncture and one that studied remotely delivered cognitive behavioral therapy. She believes care coordination could lead to more patients receiving effective treatment: “While there are a variety of evidence-based approaches to reduce pain and improve functioning, connecting people with chronic pain with effective services and helping them to combine such services in a manner best tailored to their needs is rare. The CARNATION Study provides an unprecedented opportunity to create this support structure in under-resourced healthcare settings that generally lack such services.”

If the study shows that care coordination tools have a positive impact on the delivery of evidence-based pain care, the tools could potentially be adopted throughout OCHIN’s network of more than 2,400 clinics in more than 40 states, and beyond.