2021 MBHR Measure: Pain Interference Response utilizing PROMIS

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Justification

Pain is among the most prevalent, persistent, and costly health conditions in clinical practice as well as the general population. Moreover, musculoskeletal pain conditions account for four of the nine most disabling diseases. [1] Chronic pain, lasting present on most days for three months or longer, is experienced by an approximate 11.2% of Americans, although some surveys have estimated this to be closer to 30% common among adults with prevalence estimates as high as 40% of adults while bothersome chronic pain affects 20 to 25 percent of adults. Chronic pain with major life activity impacts affects about 10 percent of the adult population. [2,3] Chronic pain is more prevalent for women than men, tends to increase with age, is mainly most commonly attributed to low back followed by and osteoarthritis pain and is reported as severe for about a third of respondents. [3] But persons with persistent pain with life activity impacts frequently report pain at multiple body sites or anatomically diffuse pain. In some populations the prevalence of chronic pain may be higher, such as in up to 50% of those who are veterans. [4] Chronic pain with life activity impacts is complex and unique to individual patients, often occurring along with comorbidities including obesity, depression, anxiety, and post-traumatic stress disorder. [5,6,7] Psychological interventions for management of chronic pain are a useful approach, that can reduce pain and catastrophizing beliefs, and improve pain self-efficacy for management, particularly in older adults.

1. Kroenke, K. (2018). Pain Measurement in Research and Practice. J Gen Intern Med, 33:1, S7-8.
2. National Center for Complementary and Integrative Health. Pain in the U.S., August, 2015. Available: https://nccih.nih.gov/news/press/08112015.
3. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain. 2010 Nov;11(11):1230-9.
4. Kerns RD, Otis J, Rosenberg R, Reid MC. Veterans’ reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. J Rehabil Res Dev. 2003 Sep-Oct;40(5):371-9.
5. Narouze S, Souzdalnitski D. Obesity and chronic pain: systematic review of prevalence and implications for pain practice. Reg Anesth Pain Med. 2015 Mar-Apr;40(2):91-111.
6. Stubbs B, Koyanagi A, Thompson T, Veronese N, Carvalho AF, Solomi M, et al. The epidemiology of back pain and its relationship with depression, psychosis, anxiety, sleep disturbances, and stress sensitivity: Data from 43 low- and middle-income countries. Gen Hosp Psychiatry. 2016 Nov – Dec;43:63-70.
7. Otis JD, Keane TM, Kerns RD. An examination of the relationship between chronic pain and post-traumatic stress disorder. J Rehabil Res Dev. 2003 Sep-Oct;40(5):397-405.

Clinical Recommendation Statement

In November 2009, the Institute for Clinical Systems Improvement (ICSI)1 released a guideline on the assessment and management of chronic pain in adults and stated that when assessing chronic pain, physicians should document the following: pain location, intensity, quality, and duration; functional ability and goals; and psychological or social factors, such as depression or substance abuse. Obtaining a baseline functional ability assessment can provide objectively verifiable information about patients’ quality of life and ability to participate in normal activities. Guidelines from the American College of Physicians (2017)2 stated that with chronic low back pain patients, clinicians and patients should initially select nonpharmacologic treatments with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). Nonpharmacologic interventions are considered as first-line options in patients with chronic low back pain because fewer harms are associated with these types of therapies than with pharmacologic options. Clinicians and patients should use a shared decision-making approach to select the most appropriate treatment based on patient preferences, availability, harms, and costs of the interventions. This is similar to an earlier Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society3, for patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits— for chronic or subacute low back pain, this included intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

1. Lambert, M. (2010). ICSI Releases Guideline on Chronic Pain Assessment and Management. Downloaded from the American Family Physician Web site at www.aafp.org/afp.
2. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017
   Apr 4;166(7):514-30.
3. Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel.* Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147: 478-491.