Objective Benefits of primary care provider (PCP) participation in pain management telementoring have been reported; however, no studies have examined within-patient changes in dose or discontinuation of long-term opioid therapy (LOT). The objectives of this nonrandomized study were to evaluate the relationship between telementoring participation and 1) LOT dose reduction and 2) LOT discontinuation and to 3) explore the relationship between LOT dose changes and patient-reported outcomes. Methods PCPs were recruited from a US Army medical center. Intervention group PCPs (N = 12) attended telementoring sessions; control group providers (N = 13) did not. Morphine equivalent daily doses (MEDD) for patients of study providers (N = 396) were extracted from the study site’s opioid database. The intervention group was subdivided based on number of sessions attended (i.e., active and low participation). Intent-to-treat and as-treated analyses were conducted using generalized estimating equations. Separate analyses evaluated the association between within-patient changes in MEDD and pain impact, depression, and anxiety (N = 40). Results Intent-to-treat analysis revealed no significant difference in MEDD reduction; however, a higher proportion of patients of intervention PCPs discontinued LOT (25% ± 3.6%) compared with control PCPs (16% ± 3.6%, P < 0.05). As-treated analyses revealed differences in MEDD reduction between active (13.2 ± 3.0) and low-participating (2.6 ± 3.0) PCPs (P < 0.01). Further, a higher proportion of patients of actively participating PCPs discontinued LOT (29% ± 4.9%) compared with control PCPs (16% ± 3.6%, P = 0.01). We found no evidence that decreased MEDD was associated with poorer self-reported outcomes within patients. Conclusions Pain management telementoring supports PCPs’ efforts to reduce reliance on LOT for chronic pain management and highlights the need for actively engaged PCP pain champions.

Chronic pain is a leading cause of disability among active duty service members in the U.S. armed forces. Standard rehabilitative care and complementary and integrative health therapies are used for chronic pain rehabilitation. However, the optimal sequence and duration of these therapies has yet to be determined. This article describes a sequential multiple assignment randomized trial (SMART) protocol being used to identify the optimal components and sequence of standard rehabilitative care and complementary and integrative health therapies for reducing pain impact and improving other patient outcomes. Active duty service members referred to Madigan Army Medical Center for treatment of chronic pain are being recruited to the Determinants of the Optimal Dose and Sequence of Functional Restoration and Integrative Therapies study. Study participants are randomized to either standard rehabilitative care (physical and occupational therapy and psychoeducation) or complementary and integrative health therapies (chiropractic, acupuncture, yoga and psychoeducation). Those participants who do not respond to the first 3 weeks of treatment are randomized to receive an additional 3 weeks of either (1) the alternative treatment or (2) the first-stage treatment plus the alternative treatment. This study will also determine factors associated with treatment response that can support clinical decision making, such as baseline fitness, pain catastrophizing, kinesiophobia, post-traumatic stress, pain self-efficacy, and biological indicators. The information gained from this research will be applicable to all integrative chronic pain rehabilitation programs throughout the U.S. Department of Defense and the U.S. Department of Veterans Affairs, and the broader rehabilitation community.

Objective Psychosocial factors are known to predict chronic pain, and the use of complementary and integrative health (CIH) therapies to address pain is emerging among military population. However, conflicting results on pain outcomes warrant additional research. This study aimed to (1) evaluate the benefit of adding a CIH pain management program to standard rehabilitative care (SRC), as compared to SRC alone, as precursor to an intensive functional restoration (FR) program; (2) identify factors that predict improvement in pain outcomes following treatment; and (3) determine the proportion of participants who experience clinically meaningful response. Design Pragmatic randomized controlled clinical trial. Participants were randomized to a 3-week course of either SRC alone or SRC+CIH (stage 1), followed by a 3- to 6-week course of FR (stage 2). Setting and Subjects Active duty service members with chronic pain. Methods Participants completed either SRC alone or SRC+CIH (stage 1), followed by a course of FR (stage 2). Patient-reported and provider-determined outcomes were collected at baseline, after stage 1, and after stage 2. A covariance pattern model with unstructured residual covariance matrix was used to compare treatment arms while accounting for dependency due to repeated measurements. Results A total of 210 service members participated. Most were Army (82%) and male (84%). Participants randomized to the SRC+CIH intervention had greater improvement in the pain impact score than those in the SRC alone group. Predictors of outcomes were baseline impact score, anger, depression, and educational status. Conclusions This study found that military service members with the highest pain impact benefit the most from interdisciplinary pain care.

Chronic pain is a significant problem among military personnel and a priority of the military health system. The U.S. Army Surgeon General's Pain Management Task Force recommends using telehealth capabilities to enhance pain management. This article describes the development and evaluation of a telehealth intervention (TelePain) designed to improve access to pain specialist consultation in the military health system. The study uses a wait-list cluster controlled clinical trial to test: 1) effectiveness of the intervention, and 2) interviews to assess barriers and facilitators of the intervention implementation. The intervention involves a didactic presentation based on the Joint Pain Education Curriculum followed by patient case presentations and multi-disciplinary discussion via videoconference by clinicians working in the military health system. A panel of pain specialists representing pain medicine, internal medicine, anesthesiology, rehabilitation medicine, psychiatry, addiction medicine, health psychology, pharmacology, nursing, and complementary and integrative pain management provide pain management recommendations for each patient case. We use the Pain Assessment Screening Tool and Outcomes Registry (PASTOR) to measure patient outcomes, including pain, sleep, fatigue, anxiety, and depression. This article reports some of the challenges and lessons learned during early implementation of the TelePain intervention. Weekly telephone meetings among the multisite research team were instrumental in problem solving, identifying problem areas, and developing solutions. Solutions for recruitment challenges included additional outreach and networking to military health providers, both building on existing relationships and new relationships.

Chronic pain significantly impairs physical, psychological and social functioning. Among military populations, pain due to injuries sustained both on and off the battlefield is a leading cause of short and long-term disability. Improving the quality of pain care for active duty service members is a major priority of the Department of Defense. This article describes an ongoing comparative effectiveness study which aims to (1) evaluate the benefit of a multimodal complementary and integrative health (CIH) pain management program when added to standard rehabilitative care (SRC) prior to an intensive functional restoration (FR) program compared to SRC alone, and (2) identify factors that predict improvement in pain impact following treatment completion. Using a randomized controlled trial design, active duty service members with pain related to musculoskeletal injury are assigned to a 3-week course of either SRC or SRC combined with CIH therapies prior to beginning a 3-week course of FR. Outcomes are collected at baseline, at the end of stage 1 treatment, post-FR, and at 3- and 6-months post-FR. Outcome measures include provider-measured functional assessments and patient-reported assessment through the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). The military health system provides a supportive environment for implementation of this research protocol. Challenges to conducting the study have included new technology systems at the study site, slower than projected enrollment, and program delivery issues. These challenges have been successfully managed and have not significantly impacted study participant enrollment and completion of study treatments.