Telecare and Pain Management

481422389Electronically based interventions in clinical care have thus far proven somewhat disappointing, as Rick and I have discussed on PodMed many times, but this week, we talk about a study utilizing electronic devices, telephone or Internet interface, and nurses to help people manage their chronic pain. The results, reported in JAMA, appear very encouraging.  Here's what they did:

Two hundred fifty people with chronic pain of at least three months duration were randomized to either usual care, administered by a physician, to manage their pain, or to automated symptom monitoring either by phone or Internet, weekly for one month, followed by every other month for months 2 and 3, and then monthly for months 4 through 12.  Subjects answered 23 questions to assess pain level, anxiety level, depression, the degree to which pain was disabling, whether current medications were being taken as prescribed and how well they were working, and whether a call with a nurse was needed.

The study utilized a stepped care analgesic optimization algorithm developed on a review of the literature relative to pharmacologic management of pain. 6 classes of analgesics were employed, ranging from acetaminophen and NSAIDs to opioids. Adjustments in type or dose of analgesic were determined by the nurse and prescribed by a study physician in the intervention group  if the subject requested a change, less than 30% improvement in the overall pain score was seen, or global improvement was not at least moderate. The control group was managed by their primary care physician.

All study participants had pain of musculoskeletal origin. People in the intervention group had greater improvement in their pain control and reductions in pain severity than the usual care group, and these results did not differ by age, gender, education level, race or socioeconomic status.  There was no difference between the telephone and Internet interface groups. Finally, when we cite that current favorite in the medical literature, number needed to treat, we see a very modest 4:1 ratio, indicating that 4 patients must be treated for one to improve significantly.  That's pretty good, considering the fact that we routinely advocate for treatments and interventions with much higher numbers, and that the intervention is inexpensive, and convenient for both patient and provider.

How about that other hot button issue right now, opioid use? Although one-third of all subjects were taking these medications at the start of the study, very few people in either group started opioids for the first time or increased their dose during the study period.  The authors opine that the systematic approach to pain assessment and medication use utilized in this study helps, and that the addition of other strategies such as cognitive behavioral therapy might further improve these results. Since pain is the most commonly reported symptom in the general population, getting our arms around best care practices is crucial.

Other topics this week include two on stroke in JAMA, pill changes and compliance in Annals of Internal Medicine, and niacin for the prevention of cardiovascular disease in NEJM.  Until next week, y'all live well.

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