Pain Program for Active Coping & Training

Pain is a common and very costly public health problem. Common chronic pain conditions are
expensive and pervasive, affecting at least 116 million American adults at an annual cost of
$560 billion in direct medical treatment costs and lost productivity, and disproportionally
affect vulnerable populations. Pain is the primary reason patients seek medical care and, as
the first point of contact, primary care providers (PCPs) deliver the majority of that care.
Unfortunately, PCPs face many challenges in managing these patients' care and often have
little specific training in pain medicine. Yet with proper system support, PCPs are in the
best position to coordinate pain management longitudinally. While pharmacotherapy is the
predominant treatment approach for many PCPs, this limits the patient's role to taking
medication, and he or she can become a passive recipient of care—leading to poor outcomes,
potential overmedication, and possible disillusionment with the medical system. Further,
increases in opiate prescribing for pain treatment—amidst increasing awareness of adverse
outcomes, including addiction—and limited efficacy suggest the importance of broader
treatment approaches that focus on patients' improvement of functioning. Although opiates may
reduce pain symptoms while prescribed, patients are unlikely to experience significant and
sustained improvements without the use of other nonpharmacologic pain management approaches.
Medical management of patients with persistent pain and complex problems is often fragmented,
which leads patients to seek a wide variety of primary and specialty care services in an
effort to manage their pain and related conditions. Such fragmented care leads to poorer
outcomes and significantly increases health care costs as patients often receive unneeded
diagnostic and medical procedures. While research has identified evidence-based
multidisciplinary behavioral treatment approaches that are effective for such patients and
can even prevent the disability associated with persistent pain when offered earlier in the
course of care, these interventions are rarely available in everyday practice settings and
will require data from pragmatic clinical trials to change the care paradigm.

To address these issues, we are conducting a large-scale, mixed-methods, cluster-randomized
pragmatic clinical trial throughout three regions of Kaiser Permanente - Northwest, Georgia,
and Hawaii. This trial will evaluate the integration of multidisciplinary services within the
primary care environment as compared to usual care in these settings. This project embeds an
intervention into everyday clinical practice flow utilizing assessment measures and
intervention staff directly from the clinical care system rather than utilizing a
research-developed and administered structure. The intervention is an integrated,
interdisciplinary program that guides all pain-related care for intervention patients. This
study compares this primary care-based intervention to usual care using systematic,
clinic-based assessments. The trial will include up to 1,000 patients and 500 primary care
providers (half of each receiving active treatment) with intervention care being delivered by
behavioral specialists, nurses, physical therapists, pharmacists, and other affiliated staff.
Patients include those selected by their primary care providers who have non-malignant
chronic pain (pain persisting for ≥ 3 months) and who are on long-term opiate therapy for the
treatment of their condition. This intervention brings together elements often available in
health plans but organized in a less integrated fashion, and it will ensure flexibility in
implementation to best fit individual clinic environments and the needs of chronic pain
patients on long-term opiate therapy.

Patient inclusion criteria are:

1. Adult (18 years of age or older) Kaiser Permanente (KP) health plan members from the
KP Northwest, KP Georgia, and KP Hawaii regions who receive their primary care
services from participating primary care providers

2. Kaiser Permanente health plan membership of at least 180 days duration

3. Long term opioid use defined by: 90+ day supply of short acting opioid spanning at
least 120 days or 2 or more long acting opioid dispense in the past 180 days

4. Pain diagnosis within the past year (based on ICD-9 or ICD-10 diagnostic codes)

5. English speaking

Patient exclusion criteria are:

1. Currently enrolled in intensive addiction medicine services or evidence of active
substance dependence

2. Cognitive impairment severe enough to preclude patient's participation in a
behavioral/lifestyle change program

3. Current malignant cancer diagnosis

4. Having received hospice or other end-of-life palliative care within past year