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Integrated Pain Management Programs

Systematic Review Draft

Open for comment through Jun 21, 2021

This draft report is available in electronic format only (Draft Report, [PDF, 2.6 MB]; Draft Appendixes [PDF, 1.2 MB]; Draft Appendix E Evidence Tables [XLSX, 152.8 KB]; Draft Appendix F: Risk of Bias Assessments [XLSX, 23.3 KB]). For additional assistance, please contact us.

Main Points

  • Integrated pain management programs improved both pain and function in patients with chronic pain at some but not all time frames compared with usual care.
  • Comprehensive pain management programs also improved function at multiple time frames and pain immediately after the program compared with usual care.
  • Comprehensive programs also improved function and pain compared with medications alone at multiple time frames.
  • Beneficial effects were usually considered small to moderate.
  • Comprehensive programs were associated with a small improvement in function short term compared with physical activity but not at intermediate or long term.  There was no improvement in pain at any time point.
  • There were no differences between comprehensive programs and psychological support alone at any time.
  • Although evidence was limited, serious harms were not reported for either program.

Structured Abstract

Objectives. To evaluate the effectiveness and harms of pain management programs that are based on the biopsychosocial model of care, particularly in the Medicare population.

Data sources. Electronic Databases (Ovid® MEDLINE®, PsycINFO®, CINAHL®, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews) from 1989 to September 23, 2020; reference lists; and a Federal Register notice.

Review methods. Using predefined criteria and dual review, we selected randomized controlled trials (RCTs) comparing integrated (based in and integrated with primary care) and comprehensive (referral based and separate from primary care) pain management programs (IPMPs and CPMPs) with usual care or waitlist, physical activity, pharmacologic therapy, and psychological therapy. Patients needed to have access to medication support/review, psychological support, and components for physical function in programs. Meta-analyses were conducted to improve estimate precision. We classified the magnitude of effects as small, moderate, or large based on predefined criteria. Strength of evidence (SOE) was assessed for primary outcomes.

Results. We included 57 RCTs; eight RCTs evaluated IPMPs and 49 RCTs evaluated CPMPs. Compared with usual care or waitlist, IPMPs were associated with small improvements in pain short and intermediate term (SOE: low) and in function short term (SOE: moderate) but there were no clear differences at other time points. CPMPs were associated with small improvements in pain postintervention (SOE: moderate) but no differences at short, intermediate, and long term (SOE: low). For function, improvements were moderate short term and small long term with no differences intermediate term (SOE: low at all time points). Compared with specific treatments, CPMPs were associated with small to moderate improvements in function and pain versus pharmacologic treatment at multiple time frames (SOE: moderate for function intermediate term; low for pain and function at all other times), and with small improvements in function, but no improvements in pain, versus physical activity short term (SOE: moderate). There were no differences between CPMPs and psychological therapy alone at any time (SOE: low). Serious harms were not reported though evidence on harms was insufficient. None of the trials specifically enrolled Medicare beneficiaries.

Conclusions. IPMPs and CPMPs may provide small to moderate improvements in function and small improvements in pain in patients with chronic pain compared with usual care. To the extent that programs are tailored to patient’s needs, our findings are potentially applicable to the Medicare population.