Translational Behavioral Medicine

, Volume 2, Issue 4, pp 523–530 | Cite as

A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework

  • Lynn L DeBar
  • Lindsay Kindler
  • Francis J Keefe
  • Carla A Green
  • David H Smith
  • Richard A Deyo
  • Katharine Ames
  • Adrianne Feldstein
Practice and Public Health Policies


Chronic pain affects at least 116 million adults in the USA and exacts a tremendous cost in suffering and lost productivity. While health systems offer specialized pain services, the primary care setting is where most patients seek and receive care for pain. Primary care-based treatment of chronic pain by interdisciplinary teams (including behavioral specialists, nurse case managers, physical therapists, and pharmacists) is one of the most effective approaches for improving outcomes and managing costs. To ensure robust integration of such services into sustainable health-care programs, evaluations must be conducted by researchers well versed in the methodologies of clinical trials, mixed methods and implementation research, bioinformatics, health services, and cost-effectiveness. Recent national health policy changes, in addition to the increasing recognition of the high prevalence and cost of chronic pain conditions, present a unique opportunity to shift the care paradigm for patients with chronic pain.


Chronic pain Interdisciplinary/multidisciplinary teams Primary care Implementation Research Pragmatic clinical trials 


  1. 1.
    Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education and research. Washington DC: The National Academies Press; 2011.Google Scholar
  2. 2.
    Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med. 2012;2:106-116.CrossRefGoogle Scholar
  3. 3.
    Cheatle MD, Klocek JW, McLellan AT. Managing pain in high-risk patients within a patient-centered medical home. Transl Behav Med. 2012;2:47-56.CrossRefGoogle Scholar
  4. 4.
    Goldenberg DL. Multidisciplinary modalities in the treatment of fibromyalgia. J Clin Psychiatry. 2008;69(Suppl 2):30-34.PubMedGoogle Scholar
  5. 5.
    Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology (Oxford). 2008;47:670-678.CrossRefGoogle Scholar
  6. 6.
    Sarzi-Puttini P, Atzeni F, Salaffi F, Cazzola M, Benucci M, Mease PJ. Multidisciplinary approach to fibromyalgia: what is the teaching? Best Pract Res Clin Rheumatol. 2011;25:311-319.PubMedCrossRefGoogle Scholar
  7. 7.
    Smith BH, Torrance N. Management of chronic pain in primary care. Curr Opin Support Palliat Care. 2011;5:137-142.PubMedCrossRefGoogle Scholar
  8. 8.
    Dobscha SK, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA. 2009;301:1242-1252.PubMedCrossRefGoogle Scholar
  9. 9.
    Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. 2009;301:2099-2110.PubMedCrossRefGoogle Scholar
  10. 10.
    Von Korff M, Balderson BH, Saunders K, et al. A trial of an activating intervention for chronic back pain in primary care and physical therapy settings. Pain. 2005;113:323-330.CrossRefGoogle Scholar
  11. 11.
    Keefe FJ, Shelby RA, Somers TJ, et al. Effects of coping skills training and sertraline in patients with non-cardiac chest pain: a randomized controlled study. Pain. 2011;152:730-741.PubMedCrossRefGoogle Scholar
  12. 12.
    Keefe FJ, Somers TJ. Psychological approaches to understanding and treating arthritis pain. Nat Rev Rheumatol. 2010;6:210-216.PubMedCrossRefGoogle Scholar
  13. 13.
    Keefe FJ, Smith SJ, Buffington AL, Gibson J, Studts JL, Caldwell DS. Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis. J Consult Clin Psychol. 2002;70:640-655.PubMedCrossRefGoogle Scholar
  14. 14.
    Bennett MI, Bagnall AM, Raine G, et al. Educational interventions by pharmacists to patients with chronic pain: systematic review and meta-analysis. Clin J Pain. 2011;27:623-630.PubMedCrossRefGoogle Scholar
  15. 15.
    Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet. 2011;377:2226-2235.PubMedCrossRefGoogle Scholar
  16. 16.
    Gallagher RM. Re-organization of pain care: neuroplasticity to health system plasticity. Pain Med. 2011;12:1-2.PubMedCrossRefGoogle Scholar
  17. 17.
    Gallagher RM. Selective, tailored, biopsychosocial pain treatment: our past is our future. Pain Med. 2007;8:471-472.PubMedCrossRefGoogle Scholar
  18. 18.
    Glasgow RE, Chambers D. Developing robust, sustainable, implementation systems using rigorous, rapid and relevant science. Clin Transl Sci. 2012;5:48-55.PubMedCrossRefGoogle Scholar
  19. 19.
    Ritzwoller DP, Sukhanova A, Gaglio B, Glasgow RE. Costing behavioral interventions: a practical guide to enhance translation. Ann Behav Med. 2009;37:218-227.PubMedCrossRefGoogle Scholar
  20. 20.
    Thorpe KE, Zwarenstein M, Oxman AD, et al. A pragmatic-explanatory continuum indicator summary (PRECIS): a tool to help trial designers. CMAJ. 2009;180:E47-E57.PubMedCrossRefGoogle Scholar
  21. 21.
    Tsang A, Von KM, Lee S, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008;9:883-891.PubMedCrossRefGoogle Scholar
  22. 22.
    Kuehn BM. Opioid prescriptions soar: increase in legitimate use as well as abuse. JAMA. 2007;297:249-251.PubMedCrossRefGoogle Scholar
  23. 23.
    Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain. 2004;109:514-519.PubMedCrossRefGoogle Scholar
  24. 24.
    Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesth Analg. 2007;105:205-221.PubMedCrossRefGoogle Scholar
  25. 25.
    Moulin DE, Clark AJ, Speechley M, Morley-Forster PK. Chronic pain in Canada—prevalence, treatment, impact and the role of opioid analgesia. Pain Res Manag. 2002;7:179-184.PubMedGoogle Scholar
  26. 26.
    Von KM, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011;155:325-328.Google Scholar
  27. 27.
    Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician. 2008;11:S63-S88.PubMedGoogle Scholar
  28. 28.
    Murray S, Wooltorton E. Alcohol-associated rapid release of a long-acting opioid. CMAJ. 2005;173:756.PubMedCrossRefGoogle Scholar
  29. 29.
    White JM, Irvine RJ. Mechanisms of fatal opioid overdose. Addiction. 1999;94:961-972.PubMedCrossRefGoogle Scholar
  30. 30.
    Staats PS, Markowitz J, Schein J. Incidence of constipation associated with long-acting opioid therapy: a comparative study. South Med J. 2004;97:129-134.PubMedCrossRefGoogle Scholar
  31. 31.
    Swegle JM, Logemann C. Management of common opioid-induced adverse effects. Am Fam Physician. 2006;74:1347-1354.PubMedGoogle Scholar
  32. 32.
    Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104:570-587.PubMedCrossRefGoogle Scholar
  33. 33.
    Davis PE, Liddiard H, McMillan TM. Neuropsychological deficits and opiate abuse. Drug Alcohol Depend. 2002;67:105-108.PubMedCrossRefGoogle Scholar
  34. 34.
    Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain. 2004;112:372-380.PubMedCrossRefGoogle Scholar
  35. 35.
    Zacny J, Bigelow G, Compton P, Foley K, Iguchi M, Sannerud C. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement. Drug Alcohol Depend. 2003;69:215-232.PubMedCrossRefGoogle Scholar
  36. 36.
    Arnold RM, Han PK, Seltzer D. Opioid contracts in chronic nonmalignant pain management: objectives and uncertainties. Am J Med. 2006;119:292-296.PubMedCrossRefGoogle Scholar
  37. 37.
    Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend. 2006;81:103-107.PubMedCrossRefGoogle Scholar
  38. 38.
    Michna E, Ross EL, Hynes WL, et al. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manag. 2004;28:250-258.CrossRefGoogle Scholar
  39. 39.
    Schieffer BM, Pham Q, Labus J, et al. Pain medication beliefs and medication misuse in chronic pain. J Pain. 2005;6:620-629.PubMedCrossRefGoogle Scholar
  40. 40.
    Breivik H. Opioids in chronic non-cancer pain, indications and controversies. Eur J Pain. 2005;9:127-130.PubMedCrossRefGoogle Scholar
  41. 41.
    Nedeljkovic SS, Wasan A, Jamison RN. Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential. Clin J Pain. 2002;18:S39-S51.PubMedCrossRefGoogle Scholar
  42. 42.
    Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manag. 1996;11:203-217.CrossRefGoogle Scholar
  43. 43.
    Savage SR. Assessment for addiction in pain-treatment settings. Clin J Pain. 2002;18:S28-S38.PubMedCrossRefGoogle Scholar
  44. 44.
    Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22:62-68.PubMedCrossRefGoogle Scholar
  45. 45.
    Harden RN. Chronic pain and opiates: a call for moderation. Arch Phys Med Rehabil. 2008;89:S72-S76.PubMedCrossRefGoogle Scholar
  46. 46.
    McLellan AT, Turner B. Prescription opioids, overdose deaths, and physician responsibility. JAMA. 2008;300:2672-2673.PubMedCrossRefGoogle Scholar
  47. 47.
    Trescot AM, Boswell MV, Atluri SL, et al. Opioid guidelines in the management of chronic non-cancer pain. Pain Physician. 2006;9:1-39.PubMedGoogle Scholar
  48. 48.
    Von KM, Deyo RA. Potent opioids for chronic musculoskeletal pain: flying blind? Pain. 2004;109:207-209.CrossRefGoogle Scholar
  49. 49.
    Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006;21:652-655.PubMedCrossRefGoogle Scholar
  50. 50.
    Loeser J. Basic considerations of pain: multidsciplinary pai programs. In: Loeser J, ed. Bonica's management of pain. 3rd ed. Philadelphia: Lippincott; 2001:363-368.Google Scholar
  51. 51.
    Loeser J. Multidsciplinary pain management. In: Merskey H, Loeser J, Dubner R, eds. The paths of pain. Seattle: IASP; 2005:503-511.Google Scholar
  52. 52.
    Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:492-504.PubMedGoogle Scholar
  53. 53.
    Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009;34:1066-1077.CrossRefGoogle Scholar
  54. 54.
    Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 2001;322:1511-1516.PubMedCrossRefGoogle Scholar
  55. 55.
    Turk D, Swanson K. Efficacy and cost-effectiveness treatment for chronic pain: an analysis and evidence-based synthesis. In: Schatman ME, Campbell A, eds. Chronic pain management: Guidelines for multidisciplinary program development. New York: Informa; 2007:15-38.Google Scholar
  56. 56.
    Jessup RL. Interdisciplinary versus multidisciplinary care teams: do we understand the difference? Aust Health Rev. 2007;31:330-331.PubMedCrossRefGoogle Scholar
  57. 57.
    Hall P, Weaver L. Interdisciplinary education and teamwork: a long and winding road. Med Educ. 2001;35:867-875.PubMedCrossRefGoogle Scholar
  58. 58.
    Pain Management Task Force. Providing a standardized DoD and VHA vision and approach to pain management to optimize the care for warriors and their families. Office of the Army Surgeon General; 2010.Google Scholar
  59. 59.
    Bair MJ, Matthias MS, Nyland KA, et al. Barriers and facilitators to chronic pain self-management: a qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Med. 2009;10:1280-1290.PubMedCrossRefGoogle Scholar
  60. 60.
    Upshur CC, Bacigalupe G, Luckmann R. “They don't want anything to do with you”: patient views of primary care management of chronic pain. Pain Med. 2010;11:1791-1798.PubMedCrossRefGoogle Scholar
  61. 61.
    Katon WJ, Lin EH, Von KM, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.PubMedCrossRefGoogle Scholar
  62. 62.
    Ell K, Katon W, Cabassa LJ, et al. Depression and diabetes among low-income Hispanics: design elements of a socioculturally adapted collaborative care model randomized controlled trial. Int J Psychiatry Med. 2009;39:113-132.PubMedCrossRefGoogle Scholar
  63. 63.
    Lin EH, Tang L, Katon W, Hegel MT, Sullivan MD, Unutzer J. Arthritis pain and disability: response to collaborative depression care. Gen Hosp Psychiatry. 2006;28:482-486.PubMedCrossRefGoogle Scholar
  64. 64.
    Rollman BL, Belnap BH, LeMenager MS, et al. Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial. JAMA. 2009;302:2095-2103.PubMedCrossRefGoogle Scholar
  65. 65.
    Glasgow RE, Klesges LM, Dzewaltowski DA, Bull SS, Estabrooks P. The future of health behavior change research: what is needed to improve translation of research into health promotion practice? Ann Behav Med. 2004;27:3-12.PubMedCrossRefGoogle Scholar
  66. 66.
    Glasgow RE, Lichtenstein E, Marcus AC. Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health. 2003;93:1261-1267.PubMedCrossRefGoogle Scholar
  67. 67.
    Glasgow RE. What types of evidence are most needed to advance behavioral medicine? Ann Behav Med. 2008;35:19-25.PubMedGoogle Scholar
  68. 68.
    Kessler R, Glasgow RE. A proposal to speed translation of healthcare research into practice: dramatic change is needed. Am J Prev Med. 2011;40:637-644.PubMedCrossRefGoogle Scholar
  69. 69.
    Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290:1624-1632.PubMedCrossRefGoogle Scholar
  70. 70.
    Pasick RJ, Hiatt RA, Paskett ED. Lessons learned from community-based cancer screening intervention research. Cancer. 2004;101:1146-1164.PubMedCrossRefGoogle Scholar
  71. 71.
    Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34:228-243.PubMedGoogle Scholar
  72. 72.
    Ellis P, Robineson P, Ciliska D, Armour T, aina P, rouwers M et al. Diffusion and dissemination of evidence-based cancer control interventions. Prepared by Oregon Health & Science University, editor. Evidence report/technology assessment: Number 79, Available at AHRQ Publication No. 03-E033, Rockville, MD, Agency for Healthcare Research and Quality; 2003.
  73. 73.
    Rogers EM. Diffusion of Innovations. 4th ed. New York: Free Press; 1995.Google Scholar
  74. 74.
    Bradley EH, Webster TR, Baker D et al. Translating research into practice: speeding the adoption of innovative health care programs. Issue Brief (Commonw Fund) 2004;1–12.Google Scholar
  75. 75.
    Green LW, Kreuter MW. Health promotion planning: An educational and ecological approach. 3rd ed. Mountain View: Mayfield Publishing Co.; 1999.Google Scholar
  76. 76.
    Wagner E. The chronic care model. 2006.
  77. 77.
    Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q. 1996;4:12-25.PubMedGoogle Scholar
  78. 78.
    Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care. 2001;24:695-700.PubMedCrossRefGoogle Scholar
  79. 79.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20:64-78.CrossRefGoogle Scholar
  80. 80.
    Stelter R. Experience-based, body-anchored qualitative research interviewing. Qual Health Res. 2010;20:859-867.PubMedCrossRefGoogle Scholar
  81. 81.
    Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009;360:1477-1479.PubMedCrossRefGoogle Scholar
  82. 82.
    Etheredge LM. A rapid-learning health system. Health Aff (Millwood). 2007;26:w107-w118.CrossRefGoogle Scholar
  83. 83.
    Detmer D, Bloomrosen M, Raymond B, Tang P. Integrated personal health records: transformative tools for consumer-centric care. BMC Med Inform Decis Making. 2008;8:45.CrossRefGoogle Scholar
  84. 84.
    DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care—a national survey of physicians. N Engl J Med. 2008;359:50-60.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Behavioral Medicine 2012

Authors and Affiliations

  • Lynn L DeBar
    • 1
  • Lindsay Kindler
    • 2
  • Francis J Keefe
    • 3
  • Carla A Green
    • 1
  • David H Smith
    • 1
  • Richard A Deyo
    • 4
  • Katharine Ames
    • 5
  • Adrianne Feldstein
    • 6
  1. 1.Kaiser Permanente Center for Health ResearchPortlandUSA
  2. 2.School of NursingUniversity of PortlandPortlandUSA
  3. 3.Duke Pain Prevention and Treatment Research ProgramDuke University Medical CenterDurhamUSA
  4. 4.Department of Family MedicineOregon Health & Science UniversityPortlandUSA
  5. 5.Kaiser Health Plan, NorthwestPortlandUSA
  6. 6.Permanente Medical Group, NorthwestPortlandUSA

Personalised recommendations