Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan Conflicts: A Randomized Clinical Trial.
OBJECTIVE
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.


METHODS
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.


METHODS
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.


METHODS
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
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.


BACKGROUND
clinicaltrials.gov Identifier: NCT00386243.
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana2Department of Medicine, Indiana University School of.
Matthew J
MJ
Bair
Rheumatology and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Dennis
D
Ang
Department of Biostatistics, Indiana University School of Medicine, Indianapolis.
Jingwei
J
Wu
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana6Department of Psychiatry, Indiana University School o.
Samantha D
SD
Outcalt
Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis.
Christy
C
Sargent
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.
Carol
C
Kempf
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.
Amanda
A
Froman
Department of Occupational Therapy, Colorado State University, Fort Collins.
Arlene A
AA
Schmid
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana2Department of Medicine, Indiana University School of.
Teresa M
TM
Damush
Department of Biostatistics, Indiana University School of Medicine, Indianapolis.
Zhangsheng
Z
Yu
Research Service, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.
Louanne W
LW
Davis
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana2Department of Medicine, Indiana University School of.
Kurt
K
Kroenke
D000328:Adult; D055826:Afghan Campaign 2001-; D000700:Analgesics / Q000008:administration & dosage*; D059350:Chronic Pain / Q000175:diagnosis* / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003131:Combined Modality Therapy / Q000379:methods; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D059352:Musculoskeletal Pain / Q000503:physiopathology*; D009736:Nursing Process; D059408:Pain Management / Q000379:methods / Q000451:nursing; D010147:Pain Measurement / Q000379:methods / Q000451:nursing; D012648:Self Care / Q000379:methods*; D016896:Treatment Outcome; D014728:Veterans
D000700:Analgesics