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Jeffery MM, Butler M, Stark A, et al. Multidisciplinary Pain Programs for Chronic Noncancer Pain [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Sep. (Comparative Effectiveness Technical Briefs, No. 8.)

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Multidisciplinary Pain Programs for Chronic Noncancer Pain [Internet].

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Guiding Questions

The questions below guided the data collection for this technical brief. Question 1 lays the groundwork for the review by examining MPPs in the context of other treatments for chronic pain. Question 2 provides important background information on contextual factors affecting MPPs—such as reimbursement, current availability of such programs, and availability of practice guidelines. These issues contribute to variation in how chronic pain is managed. With the background information provided by Questions 1 and 2, Question 3 focuses on the current evidence evaluating MPPs, using a specific operational definition of MPP. The variation across studies in how MPP is defined has contributed to confusion in this area of research; thus, a consistent operational definition of MPP is fundamental to this review. (Refer to Appendix A for further definitions of terminology and acronyms used in this report.) Given a consistent definition of MPP, we then describe: what populations were studied, the detailed components of the treatment program, and the health outcomes and harms that were measured in these studies. For studies in which a comparison treatment group was used, we note how the comparison group relates to the study treatment group with regard to any prior pain therapy. After reviewing the published studies to obtain a “lay of the land” for this body of literature, in Question 4 we explore the implications of further diffusion of MPPs, identify ethical issues, key areas of uncertainty and implications for research.

Question 1. The Existing Technology

What different types of comprehensive approaches to chronic pain management have been proposed or used in clinical practice?

  1. What are the theoretical advantages/disadvantages of these approaches when compared to current practice?
  2. What are the potential safety issues?

Question 2. The Context in Which the Technology Is Used

  1. How widely available are MPPs; how widely are they used?
  2. What kind of staffing and what type of training is required or desirable?
  3. What is the role of accreditation of MPPs?
  4. What are other important contextual issues (e.g., third-party payment, carve outs)?

Question 3. The Current Evidence of the Technology

In studies examining the effectiveness of MPPs (defined as including medical, behavioral, physical reconditioning, and educational components) for adults with chronic noncancer pain:

  1. What chronic pain populations (excluding patients with cancer) were included in studies of MPPs?
    1. What clinical conditions were present in the included patients?
    2. Had the patients already failed standard pain treatment? If so, what kind? Or were patients in the process of obtaining standard treatment for pain?
    3. How did the comparison group, if any, relate to the treatment group (e.g., on what characteristics were they matched)?
    4. What other inclusion/exclusion criteria (e.g., psychological or physical comorbidities, worker compensation status, third-party litigation status, active chemical dependency, etc.) were used?
    5. What patient characteristics (those not controlled by inclusion/exclusion criteria) have been tested for interactions with MPP treatment that affect outcomes?
  2. Within a broad operational definition of an MPP requiring four components (medical, behavioral, physical reconditioning, and educational), what models (combinations of specific components) of an MPP for patients with chronic noncancer pain have been studied with regard to effectiveness?
    1. With what alternative treatment was the MPP compared?
    2. What structure and process variables in MPPs that potentially affect outcomes have been tested in studies of MPPs? Examples include length of treatment (length of each session, sessions per week, number of weeks), group versus one-on-one sessions, in-patient versus out-patient treatment, pain medications, discipline of person who provided treatment, degree of coordination of services, staff turnover, emphasis of the program, and source of referrals to the MPP.
  3. What outcomes were assessed (short-term and long-term)?
    1. How were they measured?
    2. When were they measured?
    3. What patient characteristics (those not controlled by inclusion/exclusion criteria) have been tested for interactions with MPP that affect outcomes?
  4. What are the potential safety issues and harms that may be associated with an MPP? (i.e. what safety issues might occur as a result of combining different therapies, over and above the safety issues related to each individual therapy)?
  5. Other important study factors:
    1. What was the study design?
    2. What was the sample size?
    3. How many patients were lost to followup (or dropped out)?
    4. In what setting (in-patient or out-patient) was the study done?
    5. In what country was the study done?
    6. What was the funding source for the study?

Question 4. The Issues

What are the implications of further diffusion of MPPs, given the state of the evidence?

  1. What key decisional uncertainties face practitioners, payers, and patients?
  2. What are the implications for equity (e.g. geographic equity)?
  3. What do key decisionmakers (patients, physicians, payers) need to know?
  4. What are specific needs to make research in this area effective (e.g., design, definition of pain program, outcome assessment tools, etc.)?

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