Welcome back to the Healing Pain Podcast with Matthew J. Bair, MD, MS

In this episode, we were discussing how to build a Stepped Care Model for the treatment and intervention of chronic pain. The Stepped Care Model for chronic pain originated in the VA health system and has been used in a number of other places. This model prioritizes the role of primary care providers in optimizing pharmacological management as well as the timely and equitable access to patient-centered evidence-based non-pharmacologic approaches.

Joining us to discuss this model is Dr. Matthew Bair. His principal research focuses on chronic pain, psychological comorbidity, and developing strategies to improve pain management in the primary care setting. He has a strong background in conducting clinical trials, developing and testing interventions that combine pharmacologic and non-pharmacologic treatments, and his funded work often contrasts pharmacological and behavioral approaches for pain management.

He has served on several national Veterans Affairs committees related to improving pain management as well as the Clinical Practice Guideline Committee at the American Pain Society. He serves as an Editorial Board Member for Pain Medicine and the Journal of General Internal Medicine. In this episode, you will learn all about a Stepped Care Model for Chronic Pain, the effectiveness of a Stepped Care Model, and the impact of chronic pain amongst veteran populations. Without further ado, let’s begin and let’s meet Dr. Matthew Bair and learn about a Stepped Care Model for Chronic Pain.

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How To Develop A Stepped Care Model For Pain Management With Matthew J. Bair, MD, MS

Dr. Bair, thanks for joining us on the show.

Joe, thank you for having me.

I’m excited to talk to you about your work, Stepped Care Model for Pain Management. It has been out there for a while. I know that the professionals in the VA system probably have heard of it. Maybe even they are using it or they are aware of it. Once we moved outside the VA system, things started to thin out a little bit because we were in a big country. There are lots of different systems and the research is not always applied. You work in the VA system and you are intimately connected to this global and national challenge that we have of chronic pain. Give us your perspective of working in the VA. How big is this problem and what is this looking like in working inside the VA system?

I’m a General Internist by training, so I practice in a primary care setting general medicine clinic in the VA. I have been doing that for many years now. Prior to practicing in the VA, I was an Army Physician. I was in the Department of Defense for seven years as well. I have a military background in terms of military medicine.

Over the years in the DoD and moving on to the VA, I have certainly seen how big of a problem chronic pain is among veterans. If you look at epidemiologic studies, chronic pain is even more common in veterans than it is in the general population. Some veterans report chronic pain in a primary care setting is up to 50% and even more common in women veterans. It is as high as 75% report pain. It is a common problem. Of course, it is costly and it is disabling, as we know.

Unfortunately, it looks like the incidence of pain, especially low back pain, is increasing among veterans. There are some studies that show the increasing incidence of chronic pain, so it is a big problem. It is again costly and disabling. Unfortunately, it is comorbid with a lot of other mental health conditions, which complicate its management and make it more difficult to treat in veterans.

Complicated, complex, and costly are often the things we were rotating around here on this show and the things that we were looking at about the treatment of pain. I know you lead a team of researchers and colleagues who are helping you look at this. How have you tried to address chronic pain in the veteran populations that you have treated?

It has been a team approach. I have been fortunate to be part of a great team for several years. We have tried to address it by conducting clinical and health services research. We have been involved in between 10 and 15 clinical trials. We were trying to fill some of the evidence base gaps to more effectively manage chronic pain.

Most of our trials have focused on patients in the primary care setting and addressing chronic musculoskeletal pain. We have done trials focused on chronic low back pain, osteoarthritis-related pain, neck pain, and fibromyalgia. We have done a variety of different trials. We have tried to develop and test interventions that combine pharmacologic and non-pharmacologic treatments and find optimal combinations of pharmacologic and non-pharmacologic. I have moved into studies looking at complementary and integrative health treatments, particularly yoga and massage for chronic pain conditions. As you mentioned, with the complexity of chronic pain, we need to find combinations of treatments to best help our patients that are veterans with chronic pain.

A combination of treatments is important. When I invite people on, oftentimes, they were researchers who are studying just one thing because in research, when you can isolate one intervention, then you can see how it works. We were all moving toward integrating the best evidence. For the person in our office or our clinic, what is the right combination of mostly active interventions that are going to help people overcome the physical, psychological and emotional challenges that they were seeing?

You have been working on this for a while. Where in this evolution did the Stepped Care Model come from? If people aren’t familiar with it, they can Google the Stepped Care Model VA System and an image will come up with that Stepped Model. Where did the idea for that come from? Can you explain what the Stepped Model is for the clinicians who are reading out there?

We learned about the Stepped Care Model for pain from a couple of early researchers in the area. One was Chuck Engel, who was in the Department of Defense initially at Walter Reed and then had moved on to the University of Washington, and Michael Von Korff. Chuck Engel had discussed stepped care treatment in the context of not pain but Persian Gulf War syndrome. Michael Von Korff studied stepped care intervention in the context of low back pain. We learned significantly from doctors Engel and Von Korff.

Stepped Care can mean different things for different people. We have used it as an intervention level. One way is to look at stepped care intervention. We have tested stepped care interventions. We have defined that as starting with a lower intensity, less costly treatment in an early step one, for example and then stepping up to more intensive, potentially more costly, complex treatments in subsequent steps, step 2 or step 3 if needed.

The stepping up is often guided by when a patient may not respond adequately. They didn’t respond well so poor responders might step up to step 2 or step 3. On a larger level, if you are talking about the Veterans Health Administration at a health system level. Since 2009, the VA has disseminated its Stepped Care Model for Pain Management. It has been a roadmap for us to guide our choice of treatments and our intensive treatments starting at a foundational level with pain education, self-care and self-management.

Step one would be primary care treatments. Step two would be specialty care treatments and step three is the multidisciplinary tertiary pain centers that the VA has. With each step, it is increased intensity and the complexity of the treatments, which aligns with the complexity of the patients or potentially the refractoriness that those patients have experienced due to previous pain treatments. Different stepped care at a health system level and then stepped care at an intervention level.

Are there 3 or 4 steps to that process?

There are four steps. It is a foundation that we believe that we want to empower veterans, not only veterans, but we know how chronic pain affects families and caregivers as well. We want to equip patients, caregivers, and family members with self-care strategies and education about pain. That is the foundation step. Step one is primary care-based treatments or what a primary care provider can fairly easily either co-located with a behavioral specialist, psychologist, or even physical therapists in primary care and easily refer. Step two is more special treatment, maybe a multidisciplinary pain clinic, and then step three is more tertiary pain centers.

It also sounds like as the steps increase, it is appropriate with the complexity of the case. It probably also is in line with cost, I’m assuming. Cost is a factor in the treatment of chronic pain because it can be costly. The typical thing that you hear is multidisciplinary. Interdisciplinary treatment is the “gold standard,” although I personally have challenges with that on a couple of different levels, but multidisciplinary care is very costly.

That is one of the reasons multidisciplinary pain centers and clinics, unfortunately, have been a dying breed. I feel so fortunate to work in the VA system because we don’t have some of those cost constraints that outside the VA does. I don’t worry about the cost as much. I don’t have to pay attention to that as some of my colleagues outside the VA need to pay attention, but you are right. With increasing complexity treatment, that often is associated with fairly significant costs.

It is not a level that we talk about a lot, but you are talking about that lower level, our services, outreach, education for the families, loved ones, and the community of veterans. That is important because you know the social aspects of their social support for someone. That community support can help drive outcomes in a positive way.

That step to me seems critical because if we can figure out ways to disseminate that stuff on a larger scale, then it starts to permeate to the general public outside the VA, which could be impactful for not only chronic pain but other chronic health conditions since chronic pain has so many overlaps. In real-life practice, what does that look like?

What I can share is what I try to do as a clinician. I certainly recognize that chronic pain affects not only the patient before me, but it affects a spouse or significant others. I often encouraged when we were discussing chronic pain treatments that the spouse, significant others, adult children, or siblings be involved in those discussions so we are all part of that team. We were all working on this together.

A major role of mine is to be an educator. It’s to educate my patients, caregivers, and family members. That is just one way and one patient at a time. That is not a broad effort, but there are broader efforts. Often, the VA has implemented things called pain schools or group visits, primarily focused on pain education and where the caregivers and family members are involved. That is a little broader reach and it was implied, which I’m intrigued by how we can make even a broader impact.

What I’m talking about is moving towards a public health campaign where we can transform how the general population views chronic pain. Learning from the tobacco cessation groups and advocacy groups in those public health campaigns or some of the anti-opioid groups are talking. We need safer treatments for chronic pain. They have combated through public health campaigns. If we can do that more broadly and in chronic pain, we might have a greater impact than inserts transform how chronic pain is viewed.

I like that stuff because that is where a lot of the advocacy work is done. Advocacy work is important. People look at it as only for not-for-profit organizations and I’m like, “No, advocacy has layers in almost every part of healthcare.” People ask me, “Why did you start a show?” I’m like, “Every week, it is a one-hour public service announcement about safe and effective ways to treat pain, and there are not too many of that.” We need more of that out there. I appreciate the first level in that model. In that model, the practitioners, the pain geeks, and pain nerds want to know, does this model work? What are the outcomes? With all the things that we were talking about, when you put it into real life, is it fruitful, so to speak?

Before I answer that, I want to commend you for all that you do in your show. I love your show, so please keep it up. To your question about, what about Stepped Care, is it effective? The short answer is yes, we found it to be effective and I can highlight specific clinical trials.

Generally, we have seen clinically significant improvement in pain intensity and pain-related function over the duration of our trials, which are anywhere from 9 to 12 months. We are finding numbers needed to treat relatively small from 5 to 12. The number is needed to treat to obtain a clinically significant improvement in pain, which was generally a 30% improvement saying pain severity or pain interference.

We have also seen some improvement on other important outcomes and those outcomes such as quality of life, depression, anxiety and sleep, which we know are common. We have seen improvements from stepped care interventions and they have generally involved a model that is included several components. One is some decision support, which guides the treating clinicians. It also generally involves some algorithm-guided medication management.

We have used studies looking at patients with pain and depression where we have had an algorithm of antidepressant use. That is our guided treatment and treatment to goal to reduce depressive symptoms as well as pain. We have used analgesic algorithms to guide treatment and done some proactive monitoring with the use of care managers. I think care managers have been critical. We have often used nurse care managers to help with that follow-up, monitoring of treatment response, and any side effects that they might be experiencing from the treatment.

It doesn’t have to be a nurse care manager. We have also used pharmacy care managers, psychologist care managers, or clinical social workers. There are three trials that we have looked at using Stepped Care and I can talk more about that if you are interested. Overall, we found that stepped care interventions have been effective on important pain outcomes.

Those algorithms are interesting because you mentioned depression. I assume you are primarily using antidepressants for that and then analgesic treatment of some sort. Looking at that data, I don’t know if you can speak about this specifically, do you find that one stands out more than the other? Obviously, medication has a place in chronic pain management for reducing pain. When you reduce pain, some other aspects do get better. The same can be said for depression. It is a huge problem in chronic pain. It is one of the major cycle social components that all of us struggle with. Are any one of those two more beneficial than the other?

From our studies, we can’t tell. When you do combination therapies, one of the challenges is, what is the most active ingredient of that? We have done a stepped care intervention where one of our trials was called SCAMP. We focused on primary care patients with chronic pain and depression. In step one, we used an anti-depressant-guided algorithm and that went along for twelve weeks. Step two, participants received a Pain Self-Management Program, which was focused on goal setting, pain-specific exercise, relaxation techniques, and some Cognitive Behavioral Therapy type strategies.

What we could not tell is which of those steps. Was it the antidepressants or was it the Pain Self-Management Program that was most effective? What we did see is that depression improved more than pain. We had significant large effects on depression, but modest effects on pain. We wonder if we would have provided an analgesic algorithm in addition to some of the pain self-management strategies that we have provided, would that have added more benefit on pain? That is what we were considering now. We need to address both the pain as well as the psychological comorbidities.

Is there a particular analgesic that you are using in that or is it an opioid?

In our studies, we haven’t focused on one particular antidepressant or one particular analgesic. We have started our algorithm with simple analgesics. Acetaminophen is the first choice. The second choice is non-steroidal anti-inflammatories orally, so naproxen or ibuprofen is generally used first, but we might use other non-steroidal. We certainly will apply topical non-steroidal as an important component of the early algorithmic steps for analgesic management.

After those early steps, depending on the pain condition, we might move into skeletal muscle relaxants such as cyclobenzaprine, tricyclic antidepressants, or in effect, as well as some sleep aid. We might work into the next step in the gabapentinoids, the gabapentin and the pregabalin. They only might work into the SNRIs such as venlafaxine or duloxetine.

In the past, we had worked on some opiate management as well. We might have started in refractory patients to doses of tramadol. We have done a study in the past where all our patients had low back pain and they were on opiates at the beginning. We were seeing if we could use more optimal management of their analgesics, we were focusing on the non-opiate analgesics at first but we did make some adjustments to their opiate management. That study was called CaMEO. It wasn’t focused necessarily on stepped care, but it was algorithmic-based management of their low back pain using primarily non-opioid analgesics.

Lots of great information there. It doesn’t surprise me that pain, in most of those studies, didn’t change a lot or change less. Oftentimes, we see that depression has to go down first, the physical function has to increase, and other factors change, then down the line, pain changes. It is interesting. The more I do this work, not that pain isn’t important, but sometimes tracking it is not probably what we should be tracking in the initial phases of things but that depression piece is an important part there.

We were talking about your research particularly, but other studies as well have been similar to some of what we were talking about. In general, pain research has minimum to moderate outcomes. In good research, we want moderate to maximum outcomes. You want to see an impact. That is why we were doing the work we were doing. We want to impact people’s lives and their health. Even with all the great minds and research we have going on, we were still at this skirting on this moderate level.

I wish I had a great answer. The simple knowledge meant that chronic pain is difficult to treat. If our metrics are improving pain severity and function, improving function is a difficult metric to attain. We need to address chronic pain like a chronic disease. Other chronic diseases like hypertension, hyperlipidemia and diabetes, usually the outcomes do not have a functional improvement.

In pain trials, our metrics are difficult to achieve. The acknowledgment that pain is hard to treat and improve on those metrics. The other thing is as pain clinical trialers and pain clinicians, we need to do a better job of addressing the comorbidities. Treating comorbidities concomitantly and those comorbidities is depression being a huge one. Often, that’s overlaid with some anxiety and sleep problems, which we know can exacerbate the pain experience.

Working in a VA healthcare system, I’m attuned to PTSD and the complexity of PTSD management. You also have issues of a substance use disorder, whether it is alcohol use disorders, opioid use disorder or other illicit drugs, which often overlap and complicate management. We need treatment models and interventions. We can’t only focus on pain is my main point. We need to try and focus on the broader experience, which often is psychological comorbidities.

The other aspect there are nutrition-related and metabolic comorbidities, which are so common in the United States of America that I’m sure are present in the VA every day.

I know not much about that area, but that is the right area for future research. There is real potential there.

What direction would you like to see your research and your group going now that you have this Stepped Care Model and it is being used in the VA? Have people outside the VA reached out to you and said, “Can you come lecture to us or talk to us about how to implement this into an average hospital?”

We have been invited to do that in some opportunities overseas, in Germany especially, opportunities in the Kaiser healthcare system and some other mainly academic programs. Some of the challenges that need to address are the implementation challenges. As we know, effectiveness in a clinical trial doesn’t necessarily mean it is effective in a clinical setting. There are still some real implementation challenges. Implementation research and understanding what facilitates the implementation of these types of models is an important next step for our research. Some of the barriers were some of the facilitators as well.

I’m particularly interested in novel treatments. As a general internist and primary care doctor, I want the better tools in my toolkit to offer patients because we know that patients need tailoring and some treatments. Some patients won’t respond to certain treatments, so we need to do a lot of trial and error. I’m interested in finding the right combination of treatments and potentially the right sequencing of treatments. Should we be starting with certain treatment and then moving to another treatment in a more effective sequence of treatments. Those are a couple of my areas for research in the future.

The research is pointing toward mixed interventions to help people but what we don’t know is what intensity we need for each intervention and, in the course of care, when should that be implemented, continued or discontinued. As you mentioned, there could be comorbidities that influence all of those. Algorithms come to mind about trying to solve some of those complex cases. The VA has shared data but other systems don’t have shared data to leverage.

The other thing is when you have large data sets like that integrated healthcare system has, it does provide other research opportunities for comparative effectiveness, looking at costs of care and healthcare utilization. Those are important issues to look at because the VA’s data system does provide that, we have upwards of five million patients within our system. That is a large number. Certainly, not everyone has pain but if you say 50% have pain, that is still over two million veterans who have pain that is seeking care in our healthcare systems. It gives us some real opportunities to do powerful comparative effectiveness research as well.

I hope everyone checks out your research on the stepped model of pain care. You can find it online by googling the stepped model for pain management and veterans and it will pop up. Dr. Bair, if people want to follow you and get in touch with you, how can they reach out to you and follow your work?

I’m happy to talk with anyone. I love talking about pain research. The simplest is to email me. My email is [email protected]. I’m on Twitter, but I’m not an active contributor to Twitter. Emailing me would be the best way. I’m happy to talk with anyone by email or set up a short phone conversation. I’m always happy to talk about the work we were doing and help others do the same work.

At the end of every episode, I ask you to share this with your friends, family and colleagues that are interested in the safe and effective management of pain. Specifically, in this case, the Stepped Care Model can be influential for large systems that are looking to decrease costs and increase the effectiveness of chronic pain. I will see you on the next episode. Thanks for joining us.

Important Links:

• Dr. Matthew Bair
• Veterans Affairs
• [email protected]
• Twitter – @Mbair1020

About Matt Bair

Research Scientist, William M. Tierney Center for Health Services Research, Regenstrief Institute