Video-telecare collaborative pain management during COVID-19: a single-arm feasibility study

Chronic pain is among the most commonand debilitating conditions in the U.S. and worldwide [1, 2], and disproportionately affects U.S. Veterans compared to the general U.S. population [1, 3, 4]. Historically, chronic pain management relied heavily on long-term opioid therapy (LTOT), though emerging evidence suggests uncertain or low efficacy [5‐7], in addition to adverse events including opioid use disorder (OUD) and opioid overdose [8]. As such, clinical practice guidelines recommend non-opioid pharmacologic and non-pharmacologic pain management approaches, continual reassessment of the benefits and harms of continued LTOT, and consideration of tapering or discontinuing LTOT if harms outweigh benefits or rotation to buprenorphine if clinically indicated, though implementation of these strategies in primary care settings face many barriers.

The COVID-19 pandemic disrupted in-person healthcare, including access to many non-pharmacologic pain management approaches. This led to an urgent need for adaptation of clinical care, particularly for patients with chronic pain prescribed LTOT whose access to evidence-based pain care may be limited due to public health precautions. To address primary care and COVID-19 related challenges, we aimed to evaluate the feasibility and acceptability of a program called Video-Telecare Collaborative Pain Management (VCPM) in preparation for a larger-scale trial. VCPM comprises three evidence-based components: opioid reassessment and tapering, buprenorphine switch and monitoring, and behavioral pain and OUD self-management [9‐16].

Feasibility and acceptability outcomes were evaluated based on descriptive statistics with defined a priori criteria, used to determine whether further evaluation was warranted. Poor feasibility or acceptability were defined as follows: 1) the majority of patients declining to trial a buprenorphine switch (> 50%), 2) low treatment satisfaction (> 50% negative satisfaction), or 3) low engagement in follow-up (< 50% attending follow-up). Given the nature of this small pilot quality improvement project, secondary outcomes were evaluated using descriptive statistics only. Analyses were performed using SPSS for Windows (Version 28; SPSS, IBM Corp, Armonk, NY).

The current quality improvement project examined the feasibility and acceptance of a novel virtual care model of pain management utilizing well-established components including opioid reassessment and tapering, buprenorphine switch and monitoring, and behavioral pain and OUD self-management [9‐16].

Broadly, the project met the identified a priori feasibility and acceptability criteria for the virtual delivery component. Across 17 months, 133 Veterans were identified as eligible for VCPM, resulting in 44 intake evaluations (44/113; 33%). Of those who completed an intake evaluation, 19 patients also received follow-up care from a VCPM CPP (19/44; 43%). The project succeeded in engaging rural Veterans who made up nearly 50% of the sample, notable in the context that, only 14% of patients with an assigned primary care provider among these two participating VHA systems are in rural areas [21, 22]. However, enrolling patients receiving LTOT to a pain management team with a clear emphasis on opioid tapering or transition can be difficult given numerous potential barriers including stigma, concerns regarding changing medications and withdrawal, and the relative unfamiliarity of buprenorphine compared to traditional opioids [23]. Novel recruitment strategies may help to bolster enrollment. For instance, peer specialists, or patients with lived experience, may be effective in encouraging other patients to trial new approaches, and VHA is expanding its use of peer specialists into primary care clinics and other new settings.

Among those enrolled, acceptability of VCPM was high, with robust satisfaction for both virtual care modalities (i.e., phone and video conferencing). Patients reported high willingness to engage with virtual care and confidence recommending the program. As would be expected for individuals choosing to engage with the program, those who attended multiple appointments with the CPP generally rated the program as more successful than those completing only an intake evaluation. Future efforts will focus on understanding reasons for lack of engagement.

Similarly, a priori criteria for success of the buprenorphine switch component of VCPM were largely met. Among those engaged in VPCM, over half trialed buprenorphine and nearly all of those maintained their buprenorphine regimen at three-month follow-up. From a harm-reduction standpoint, VCPM was successful in tapering opioids or transitioning to buprenorphine with a majority of patients. Acceptability of the buprenorphine switch was generally favorable, with patients reporting moderate or high willingness to trial buprenorphine, view of the buprenorphine switch as successful, and confidence recommending to a friend.

Preliminary findings are encouraging, as individuals who continued to engage with VCPM exhibited greater MEDD reductions and indications of improved pain outcomes compared to those completing only a baseline intake. It is important to note, however, the single-arm nature and emphasis as a quality improvement project preclude comparisons to traditional, in-person pain management interventions.

The present quality improvement project provides initial support for VCPM and the virtual delivery of multi-modal pain management interventions. Within the VHA system, virtual interventions offer the ability to markedly increase the reach of programs designed to assist primary care providers, particularly among regions where maintaining a specialized care team is difficult. Larger effectiveness trials are needed to 1) compare VCPM to other pain management interventions and 2) ensure non-inferiority of virtual interventions and 3) evaluate VCPM among more diverse populations (e.g., across demographic variables and pain conditions).