Using a stepped-care model of pain management in primary care has been shown to strengthen pain management practices in the primary care setting, as well as improve the interface between primary and specialty care and increase the use of nonopioid medications for pain, according to a study published in Pain Medicine.

Researchers analyzed veteran patients enrolled in the VA Connecticut Healthcare System who reported moderate to severe pain to examine trends in prescribing and referral practices of primary care clinicians; these patients were then compared with other veterans seen in primary care. From July 2008 to June 2013, electronic health record data were extracted that included demographic variables, pain intensity ratings, and healthcare use outcomes (ie, primary care visits and referrals to specialty pain care services).

Those included in the pain cohort were veterans who had ≥1 documented pain intensity rating of at least moderate severity (≥4 on a scale of 0 [no pain] to 10 [worse pain imaginable]) associated with a primary care visit during the study year. Veterans in the nonpain cohort were all veterans seen in primary care with either no indication of pain or mild pain intensity (ratings 1-3).

Continue Reading

Long-term opioid use was defined as receipt of at least 90 consecutive days of prescriptions for Veterans Health Administration class CN101 drugs; these include codeine, fentanyl, hydrocodone, methadone, morphine, oxycodone, oxymorphone, and hydromorphone. Healthcare use included mental health, clinical health psychology, physical therapy, occupational therapy, neurology, pain medicine, and chiropractic referrals from primary care providers and visits in these specialty care clinics. Also examined were referrals to specialty services by primary care providers, as well as specialty service attendance by the veteran patient. Multimodal pain care included patients receiving a nonopiod pain prescription, as well as at least 1 encounter with a specialty pain service.

A total of 31,286 unique veteran patients had at least 1 visit with a documented pain intensity rating of ≥4 in any of the 5 years of the study. Mean age of patients in the pain cohort was significantly younger than that of those who were not in the pain cohort (68.4 vs 62.1 years). Average pain intensity rating was 6.5 in year 1, increasing to 6.8 in year 5 for patients in the pain cohort; these patients were also seen more frequently in primary care than were those not in the pain cohort (3.4 vs 2.2 visits, respectively). Long-term opioid therapy decreased from 4.2% in the first year of the study to 3.3% in the fifth year, whereas nonopioid medication use increased from 36.7% to 39.8%.

Related Articles

An increase was found in specialty service visits, especially in physical and occupational therapy for those in the pain cohort, and particularly in the last 2 years of the study. The number of veterans with at least 1 documented visit to a specialty service increased from 43.4% in the first year to 51.8% in the fifth year, and the proportion of veteran patients who received a nonopioid pain prescription as well as a referral to a specialty pain care service increased from 24.5% in the first year to 29.0% in the fifth year.

“Consistent with recommendations from multiple groups encouraging multimodal pain care, we found increased referrals to and receipt of several different pain-relevant specialty services over time,” the authors concluded. “At the same time, about half of all veterans reporting moderate to severe pain were not seen for pain outside of primary care, perhaps indicating that our efforts to build the capacity for pain management within primary care were successful.”


Edmond SN, Moore BA, Dorflinger LM, et al. Project STEP: implementing the Veterans Health Administration’s stepped care model of pain management. Pain Med. 2018;18(suppl_1):S30-S37.