Project Title: Causal Effects of Whole Health Approaches to Pain and Opioid Use Disorder: Strengthening the Evidence to Enhance Implementation at VA

Principal Investigator: Elizabeth Oliva, PhD

VA Location: VA Palo Alto Health Care System

Co-Investigators: Jodie Trafton, PhD; Jill Glassman, PhD; Robin Kinnard, DrPH

Project Summary: Studies providing evidence that Whole Health services (WH) reduce the number of prescribed opioids and downstream invasive interventions in patients with chronic pain at VHA have been limited in their ability to make strong causal inferences by their need to rely on observational data from patients who are not randomly assigned to WH services. While these studies have adjusted for potentially biasing factors that are measurable using analytic techniques such as propensity score weighting, it remains likely that there are unmeasured biasing factors such as patient openness to WH services. In the present study, we will use an instrumental variable (IV) 2-stage regression technique that controls for unmeasured confounders to examine the effects of WH services on pain/OUD outcomes. By applying this new analytic technique to the evaluation of WH effects on pain outcomes we aim to strengthen the evidence base for WH approaches by triangulating across bias control methods in observational studies. Additionally, varying the WH services included in the IV will allow us to provide guidance on particular WH services with the strongest evidence.

Project Title: Utilization of Mindfulness Therapies as Adjunct Treatment for Veterans Prescribed Medication for Opioid Use Disorder (MOUD)

Principal Investigator: Vanessa Somohano, PhD, MA

VA Location: VA Portland Health Care System

Senior PI: Travis Lovejoy, PhD, MPH

Project Summary: While evidence to support the use of mindfulness-based therapies as an effective adjunct treatment to medications for opioid use disorder (MOUD) has been established, the extent to which these therapies are being utilized within VA settings among those prescribed MOUD is unknown, and their impact on MOUD retention has yet to be studied. Given the heightened risks associated with substance relapse, challenges with MOUD treatment adherence, and evidence of enhanced MOUD treatment using mindfulness-based therapies, it is critical to understand the extent to which mindfulness-based therapies are being utilized among individuals prescribed MOUD within VA and how engagement in mindfulness therapies may be associated with MOUD retention. The aims of this study are to, 1) describe the proportion of VA patients nationally prescribed MOUD who utilize mindfulness therapies, 2) characterize the association of mindfulness therapy utilization with MOUD retention using an observational cohort study design, and 3) conduct qualitative interviews with N=30 MOUD-prescribing providers to understand barriers and facilitators to mindfulness therapy engagement as adjunct treatment for MOUD. Results from this study will elucidate utilization of and barriers and facilitators to dissemination of mindfulness, yoga, and tai chi therapies among individuals prescribed MOUD.

Project Title: Barriers and facilitators to providers' use of the Personal Health Inventory (PHI) with Veterans on long-term opioid therapy

Principal Investigator: Anne Black, PhD

VA Location: VA Connecticut

Project Summary: Best practice guidelines for chronic pain management align with the emerging Whole Health approach to care within the Department of Veterans Affairs (VA), sharing priorities of health education, self-management, and integration of complementary and integrative health (CIH) modalities as part of clinical care. One Whole Health tool, the Personal Health Inventory (PHI), is designed to facilitate personal health planning across life domains and ground goal setting in a Veteran’s mission, aspiration, and purpose. For providers working with Veterans on long-term opioid therapy (LTOT) for whom harms outweigh benefits, or reassessment of chronic pain management is indicated by best practice, the PHI may be particularly useful to engage discussion around treatment goals and facilitate shared decision-making to improve care and well-being. However current data indicate that documented use of the PHI with Veterans on LTOT remains rare to date. The Aims of this study are to determine barriers and facilitators to use of the PHI in the context of chronic pain management by (1) administering a new survey, informed by VA Operations leaders, to providers working with Veterans on LTOT and (2) conducting qualitative interviews with a subset of respondents to gain insight into survey responses. With VA Operations and other research partners, we will consider the implications of study results for intervention to broaden use of the PHI in chronic pain management.

Project Title: Cross-System Whole Health and Complementary and Integrative Health Resource Sharing for Chronic Pain Management

Principal Investigator: Rendelle Bolton, PhD, MPH

VA Location: VA Bedford Healthcare System

Co-Investigators: Barbara Bokhour, PhD & Varsha Vimalananda, MD, MPH

Project Summary: Whole Health (WH) and complementary and integrative health (CIH) therapies are first-line approaches for managing chronic pain. Factors limiting their accessibility contribute to WH and CIH under-utilization among patients with chronic pain, particularly among rural-living Veterans. Innovative approaches that expand WH and CIH access while maximizing existing resources are needed. This study will describe (1) how current WH and CIH resource-sharing approaches (e.g., clinical resource hubs, hub-and-spoke models, resource sharing agreements) in VA are organized, implemented, and coordinated; and (2) apply lessons learned in partnership with VISN 1 to inform and evaluate local resource-sharing efforts. Results will lead to the development of an implementation resource guide.

Project Title: Rapid Quality Improvement and Evaluation of an Acupuncture Therapy Clinic for Peri/Post Menopausal Women Veterans with Chronic Pain (A-MVP)

Principal Investigator: Felice Indindoli, D.Ac., L.Ac., dipl Ac (NCCAOM)

VA Location: Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts; San Francisco VA Health Care System

Senior PI* & Co-Investigator: *Carolyn Gibson, PhD, MPH & Lisa J. Taylor-Swanson, PhD, L.Ac.

Project Summary: This study will conduct a program evaluation of the ENRM Veterans Hospital’s Women’s Acupuncture Pain Clinic. Almost half of those seeking care in this clinic are of typical peri-and postmenopausal age, and menopause status and related symptoms contribute to pain management considerations. Findings from this study will be used to improve and refine clinic procedures, including clarification of resource needs for peri- and postmenopausal women Veterans with chronic pain. The findings of this study may be used to improve implementation and expansion of similar clinics across VA, to promote programs to improve chronic pain and common comorbidities in women Veterans across the lifespan, and to support future efforts to study acupuncture and CIH interventions for multi-modal menopause-related care. To our knowledge, this is the only VA clinic offering acupuncture pain care in a gender-specific setting.

Project Title: Exploring the Use of Whole Health to Support the Care of Pregnant Veterans

Principal Investigator: Aimee Kroll-Desrosiers, PhD

VA Location: VA Central Western Massachusetts Healthcare System

Co-Investigators: Kristin Mattocks, PhD, MPH; Megan Brault, PhD; & Anne Black, PhD

Project Summary: Nearly 15% of pregnant Veterans experience chronic musculoskeletal pain, but only a small proportion receive any CIH or Whole Health care during pregnancy, despite a desire for greater access to these types of pain management strategies. This project seeks a better understanding of Whole Health availability, use, referrals, and practices for pregnant Veterans with chronic pain from the perspective of VA women’s health providers and Whole Health leaders. Our objectives are to explore Whole Health utilization and referral patterns for pregnant Veterans at VA facilities to understand what is needed to improve communication and/or use of Whole Health among pregnant Veterans. These findings will be translated into an implementation blueprint to further develop strategies that increase the uptake of Whole Health among this growing population of Veterans.

Project Title: Piloting a Gender-Sensitive Brief Acceptance and Commitment Therapy Group Treatment for Women Veterans with Chronic Pelvic Pain

Principal Investigator: Derrecka Boykin, PhD

VA Location: Michael E. DeBakey VA Medical Center, Houston, TX

Senior PI* & Co-Investigators: Jeffrey Cully, PhD*; Lilian Dindo, PhD; and Mackenzie Shanahan, PhD

Project Summary: Chronic pelvic pain (CPP) is a debilitating pain condition that disproportionately affects women veterans (30% vs. 16% of nonveteran women vs. 3% of men). Pain intensity and disability are further exacerbated by psychosocial factors (such as depression, anxiety, posttraumatic distress) that may not be fully addressed through pharmacological and surgical interventions. In this pilot randomized trial, we will test the feasibility and acceptability of a brief Acceptance and Commitment Therapy (ACT) group treatment for women veterans experiencing CPP. ACT is recognized as a first-line nondrug treatment for pain conditions and, as a transdiagnostic psychotherapy, provides a unified approach to the treatment of co-occurring medical and psychiatric disorders. This pilot study builds on our previous work adapting an empirically supported one-day ACT workshop to the specific pain needs and care preferences of women veterans based on their feedback. This work also aligns with priorities to expand women’s health services within the Veterans Health Administration.

Project Title: Feasibility and Acceptability of Group Pain Reprocessing Therapy for Veterans with Chronic Back Pain

Principal Investigator: Joseph Frank, MD, MPH

VA Location: VA Eastern Colorado Health Care System, Aurora, CO

Co-Investigator: Yoni Ashar, PhD

Project Summary: Pain Reprocessing Therapy (PRT) is a novel psychological treatment with promising results from an initial clinical trial among civilians with chronic back pain. This study will assess the feasibility and acceptability of group-delivered PRT for Veterans with chronic back pain in the context of an interdisciplinary VA pain management team. We will deliver an 8-session, weekly group intervention to 4 groups of Veterans using a wait-list control design. We will conduct a mixed-methods evaluation with brief structured surveys and focus groups.

Project Title: Feasibility and Acceptability of an Online Acceptance and Mindfulness Based Program for Chronic Pain and Substance Use

Principal Investigators: Erin Reilly, MEd, PhD and Victoria Ameral, PhD

VA Location: VA New England Healthcare System, Bedford, MA

Senior PI: Megan Kelly, PhD

Project Summary: Chronic pain is a debilitating condition that disproportionately impacts Veterans, who are diagnosed at particularly high rates (47 - 56%) and with a 40% greater rate of severe pain than non-Veterans. Co-occurring substance use disorders are also common among Veterans with chronic pain and exacerbate both the intensity and life interference of chronic pain issues. Evidence-based interventions for chronic pain that target transdiagnostic processes of relevance for substance use, such as mindfulness and acceptance, hold particular promise for this population. Unfortunately, less than half of Veterans receive such therapeutic interventions, despite rising rates of co-occurring chronic pain and substance use among Veterans. This proposed project will provide an online acceptance and commitment therapy-based intervention, Veteran ACT for Chronic Pain, using seven weekly modules to improve pain-related functioning and quality of life for Veterans with chronic pain and comorbid substance use disorder. We will make revisions to existing website content and conduct a Stage IA feasibility pilot of the modified website, with primary outcomes including ease of recruitment, retention, treatment receptivity, sustained participation, and the assessment process (n=20 total).

Project Title: Exercise-Induced Hypoalgesia in Women Veterans with Chronic Musculoskeletal Pain: A Comparison of Low, Medium and High Intensity Interval Training

Principal Investigator(s): Alice Schmidt Kehaya, MD

VA Location: VA Portland Health Care System, Portland, OR

Senior PI* & Co-Investigator: Travis I. Lovejoy, PhD, MPH* and Kerry Kuehl, MD, DrPH Project Summary: This study will compare various intensities of bicycle interval training in women Veterans with chronic musculoskeletal (MSK) pain. The project will harness the phenomenon of Exercise-Induced Hypoalgesia – a short-term reduction in pain sensitivity after exercise – and measure acute and delayed effects of exercise on various measures of pain. The goal of this feasibility study is to inform a larger, future trial that will elucidate the optimum “dose” of interval exercise to minimize both short- and long-term pain and promote adherence to exercise.

Project Title: Better Options for Chronic Cancer Pain: Buprenorphine to Reduce LTOT in Veterans with Chronic Cancer Pain

Principal Investigator(s): Maria Silveira, MD, MA, MPH

VA Location: Ann Arbor VA Medical Center, Ann Arbor, MI

Co-Investigator: Karleen Giannitrapani, PhD

Project Summary: There is little evidence that opioids work for chronic cancer pain; indeed, most cancer survivors on opioids report their pain is inadequately controlled. Despite this, many Veteran cancer survivors continue opioids indefinitely. There is an urgent need for mitigating the risks of long-term opioid therapy (LTOT) without jeopardizing pain management for cancer survivors at the VA. Our long-term objective is to determine if rotation from opioids to buprenorphine, can achieve the same outcomes in Veterans with chronic cancer related pain as it does in those with chronic musculoskeletal pain (reduced long term opioid use without worsening pain). Our objective in this application is to investigate the feasibility of a multisite, randomized controlled trial (RCT) that will examine the effectiveness this approach in comparison to opioid tapering.

Project Title: An Exploratory Investigation of VA Opioid Treatment Program (OTP) Policy

Principal Investigators: Jessica Wyse, PhD, MPP

VA Location: VA Portland Health Care System, Portland, OR

Senior PI* & Co-Investigator(s): Travis Lovejoy, PhD, MPH*; and Adam Gordon, MD, MPH*; and Allison Lin, MD, MS

Project Summary: The COVID-19 pandemic initiated the first major federal reform to opioid treatment programs (OTPs) in decades, substantially relaxing the attendance requirements and expanding access to telehealth. Emergent research suggests that these policy changes dramatically lowered the barriers for patients to receive methadone and have thus far not been shown to have negatively impacted patient outcomes. While research conducted outside of VA has shown significant variation in adoption of relaxed guidance across states and facilities, response among VA OTPs remains unknown. This mixed methods study will elucidate variation in OTP treatment practices through two Aims. Aim 1 will conduct interviews with medical directors of VA OTPs to identify a) national variation in OTP treatment practices, b) explanations for decision-making regarding adoption and c) perceptions and beliefs regarding proposed federal regulatory changes. Aim 2 will use CDW paired with operational data to describe the characteristics of VA OTPs that adopted relaxed guidance and test for differences across facility and patient characteristics.

Project Title: Engaging Hospitalized Veterans in Non-pharmacologic Treatments for Chronic Pain

Principal Investigator(s): Meilen Chang Munoz, MD, PhD, MS

VA Location: Sacramento VA Medical Center, Mather, CA

Senior PI & Co-Investigator(s): Stephen Henry, MD; Regina Godbout, MD; Marianne Matthias, PhD; and Dinithi Iddawela, MD

Project Summary: This project will be a pilot randomized trial, with the primary goal of assessing feasibility and data collection needed for a subsequent fully powered study. We will recruit and randomize patients prescribed opioids for chronic pain at baseline who are hospitalized for problems not related to pain.

Patients assigned to the intervention arm will be asked to view a patient education video, and then they will receive a brief introduction to 3 non-pharmacologic outpatient treatment strategies that are readily available at Sacramento VAMC and were endorsed by the VA State-of-the-Art conferences: yoga, standard acupuncture and mindfulness-based stress reduction. Study participants will choose whichever treatments they are interested in and this information will be relayed to the inpatient medical team. Study measures, including whether a referral was made at discharge for each treatment option, whether follow through is documented and the patient’s baseline prescribed opioid use will be collected once patients have completed intervention and control activities.

Project Title: Proactive Messaging to Facilitate Veteran Engagement in Non-Pharmacological Pain Treatments

Principal Investigator(s): Ashley Griffin, PhD and Sarah Javier, PhD

VA Location: VA Palo Alto Health Care System, Palo Alto, CA

Senior PI & Co-Investigator(s): Amanda Midboe, PhD; Marianne Matthias, PhD; Donna Zulman, MD, MS; and Stephanie Shimada, PhD

Project Summary: The proposed study aims to elicit Veterans’ preferences for both content of proactive messages and preferred outreach modality to facilitate engagement in non-pharmacological psychological approaches for chronic pain (cognitive-behavioral therapy [CBT], mindfulness-based stress reduction [MBSR], and acceptance and commitment therapy [ACT]). Our work is informed by the eHealth Enhanced Chronic Care Model and Theory of Planned Behavior. In Aim 1, we will utilize a user-centered, rapid prototyping approach with 10-15 Veterans from Veteran engagement panels to refine messages promoting engagement in non-pharmacological psychological chronic pain treatments. In Aim 2, we will conduct individual interviews with 30 diverse Veterans with chronic pain to examine their preferences for the modality and timing of communication, and perceived impact of proactive messages refined in Aim 1. Our study will inform future research spanning the topic areas of health informatics, chronic pain, and health disparities.

Project Title: Pilot Study Testing the Feasibility to Implement Virtual Monitoring of Pain, Enjoyment of Life, and General Activity (PEG) For Veterans Seeking On-Station Chiropractic Care

Principal Investigator: Charles Penza, DC, PhD

VA Location: Orlando VA Healthcare System, Orlando, FL

Senior PI & Co-Investigator(s): Matthew Bair, MD

Project Summary: This project develops a partnership between clinic and research services within the Orlando Veterans Administration Health Care System (OVAHCS) to virtually monitor pain severity and interference before, during, and after receiving chiropractic care that is asynchronous to health care visits. More specifically, we aim to assess the feasibility to use the HSR&D funded initiative Patient Engagement, Tracking, and Long-term Support (PETALS) platform to use short message system (SMS) text messaging to monitor weekly Pain, Enjoyment of Life, and General Activity (PEG) scores in Veterans seeking on station chiropractic services. Adopting this technology-aided approach minimizes clinical staff burden of collecting week-to-week patient reported outcomes and has the potential to enhance our understanding of treatment response trajectories.

Project Title: Association of Nociplastic Features with Functional Status and Treatment Utilization in Aging Veterans with Chronic Low Back Pain

Principal Investigator(s): Victoria Powell, MD

VA Location: LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI

Senior PI & Co-Investigator(s): Sarah Krein, RN, PhD; Maria Silveira, MD, MA, MPH; Pooja Lagisetty, MD, MSc; Neil Alexander MD, MS; and Daniel Clauw, MD

Project Summary: One-third of all Veterans report chronic low back pain (CLBP), and many older adults experience little or no functional improvement despite current treatment. Central sensitization, or “nociplastic” pain is a distinct etiology whereby altered central nervous system processing amplifies physical sensations and imbues them with emotional significance. The goal of this project is to ascertain the role that nociplastic features play in older Veterans with CLBP. We plan to elucidate the relationship between nociplastic features, functional impairment, and treatment utilization (including opioids). A better understanding of these relationships may lead to targeted intervention development to improve overall function in older Veterans with CLBP.

Project Title: Development of a Group Psychotherapy Protocol for Pain and Co-occurring Substance Use

Principal Investigator(s): Danielle Wesolowicz, PhD

VA Location: VA Connecticut Healthcare System, West Haven, CT

Senior PI & Co-Investigator(s): Sara Edmond, PhD

Project Summary: Pain and substance use frequently co-occur, with individuals reporting use of substances to cope with pain and pain as a barrier to cessation. Our team will develop a group-based, peer-supported intervention incorporating Dialectical Behavior Therapy (DBT) skills to improve management of co-occurring substance use and chronic pain. Specifically, we aim to identify intervention objectives, select theoretical methods, and solicit feedback regarding intervention protocol prototypes to inform a future pilot trial of the intervention.

Project Title: Organizational Context and Variation in CIH Use among Veterans with Chronic Pain within the Whole Health System of Care

PI Name: Rendelle Bolton, PhDc, MPH, MSW, MA

VA Location: VA Bedford Healthcare System

Co-investigator: Barbara Bokhour, PhD

Project summary: Only a fraction of the five-million Veterans with chronic pain in VA engage in complementary and integrative health (CIH) therapies, with considerable variation in use across VA medical centers despite resources devoted to improving their implementation as part of the Whole Health System of Care. This multiple case study examines how organizational context influences variation in complementary and integrative health use among Veterans with chronic pain. Using qualitative data previously collected over a 2-year period, we will compare how six VA Whole Health Flagship Medical Centers with high and low levels of CIH utilization have structured CIH delivery in their Whole Health Systems of Care, promoted its adoption among patients and providers alike, and addressed implementation barriers/facilitators.

Project Title: Emotional Awareness and Expression Therapy: A Feasibility Pilot in Women Veterans with Chronic Overlapping Pain Conditions

PI Name: Mary A. Driscoll, PhD

VA Location: VA Connecticut Healthcare System

Co-investigators: Alicia Heapy, PhD & Brandon Yarns, MD

Project summary: Relative to men, women Veterans with chronic pain are more likely to be plagued by chronic overlapping pain conditions (COPCs) which are often accompanied by high rates of trauma and psychosocial distress. Traditional psychological interventions for chronic pain do not address disrupted emotional and relational processes. Emotional Awareness and Expression Therapy (EAET) does and early work suggests it may yield promise for those with COPCs. However, it has not been tested with women

Veterans utilizing VA care, a group that is acknowledged to be more medically and psychiatrically complex than the predominantly civilian sample for whom EAET has been shown to be safe and effective. Nor has EAET been tested in a virtual format, which would make it more accessible for women Veterans who cite logistical and healthcare system barriers to care. The proposed study is an uncontrolled feasibility pilot in which eighteen women Veterans with fibromyalgia or non-specific back pain will participate in an eight-week EAET group-based protocol, delivered virtually.

Project Title: A Mixed Methods Feasibility Study of Integrated Tele-Yoga Therapy for Midlife and Older Women Veterans with Chronic Pain

PI Names: Carolyn Gibson, PhD, MPH & Francesca Nicosia, PhD, C-IAYT

VA Location: San Francisco VA Health Care System

Co-investigators: Karen Seal, MD, MPH & Alison Huang, MD, MAS

Project summary: This project is a pilot feasibility study of an eight-week, video-based tele-yoga therapy program for midlife and older women Veterans with chronic pain. Findings will guide planning for a future pragmatic hybrid implementation-effectiveness trial of group-based tele-yoga therapy to improve patient-centered pain and mental health outcomes for women Veterans with chronic pain and common mental health comorbidities. The project will also inform the integration of clinical Yoga Therapists into collaborative care settings, providing a whole health model for the management of chronic pain and other chronic health conditions.

Project Title: Exploring Pain Management Strategies for Perinatal Veterans

PI Name: Aimee Kroll-Desrosiers, PhD

VA Location: VA Central Western Massachusetts

Co-investigator: Kristin Mattocks, PhD, MPH

Project summary: This study seeks a better understanding of pain-related conditions in and complementary and integrative health (CIH) pain management strategies among perinatal Veterans. Our intent is to learn more about discussions that occur between VA providers and women Veterans regarding management of pain-related conditions prior to or during pregnancy. Additionally, we will explore topics related to pain management and treatment for pregnant Veterans, on which there is virtually no existing literature. We will identify types of CIH approaches acceptable to pregnant and postpartum Veterans and explore whether CIH pain management interventions are currently integrated into care and recommended for perinatal Veterans.

Project Title: Optimizing Opioid Safety in End-Stage Kidney and Liver Disease

PI Name: Jessica Ma, MD

VA Locations: VA Palo Alto, Durham VA, and VA Connecticut

Co-investigators: Karl Lorenz, MD, Karleen Giannitrapani, PhD, Jessica Merlin, MD, Anne Black, PhD, and William Becker, MD

Project summary: Opioids are a commonly used therapy in patients with renal and hepatic insufficiency. While there is pharmacologic evidence suggesting that some opioids are safer than others, changes in drug metabolism and availability in end-stage liver and kidney disease can increase risk of significant adverse events. Our project will evaluate significant adverse events in patients with end-stage liver and kidney disease and compare to those without these conditions to have a better understanding of the risks of using specific opioids in this population.

Project Title: Admission as Disruption? A Retrospective Cohort Study of Buprenorphine Treatment Continuation in Hospitalized Veterans

PI Name: Hilary Mosher, MD

VA Location: Iowa City VA

Co-investigators: Brian Lund, PharmD & Katherine Hadlandsmyth, PhD

Project summary: The VA continues to expand access to medication therapy, specifically buprenorphine, for opioid use disorder (MOUD). These positive developments create a challenge and opportunity in improving the hospital and perioperative treatment of Veterans with chronic pain and/or opioid use disorder. This work aims to quantify current VA practice patterns in perioperative hospital-based management of surgical patients taking buprenorphine prior to hospitalization and contrast with practice during medical hospitalizations. We will then determine whether inpatient buprenorphine prescribing patterns are associated with post-hospitalization retention/re-engagement in MOUD treatment.

Project Title: A Pilot Study Evaluating Acceptability and Feasibility of Text-Messaging Based Assessment for Rural Veterans with Chronic Pain

PI Name: Krista Scorsone, PhD, RN, PMHNP-BC

VA Location(s): VA Eastern Colorado Health Care System

Co-investigator: Joseph Frank, MD, MPH

Project summary: We aim to evaluate the feasibility of prospective patient-reported outcome assessment and self-management support using a text messaging app to track pain-related function and overall experience among Veterans receiving care for chronic pain management in the VA Community Care Network (CCN). We will also explore Veterans’ experiences accessing chronic pain management in the VA CCN. These findings will inform future interventions to improve the quality and safety of care for rural Veterans.

Project Title: Feasibility, Pain and Functional Outcomes of a Novel Mixed Reality Based System to Manage Phantom Pain for Patients with Lower Limb Amputation: A Pilot Study

PI Name: Thiru M. Annaswamy, MD, MA; North Texas VA Healthcare System, Dallas, TX

Description: This study intends to use the Mixed Reality based system for MAnaging Phantom Pain (Mr.MAPP), a virtual reality system that can guide veterans in different exercises and therapies in order to treat phantom limb pain. This is a virtual mirror therapy treatment that is conducted over one or more months in the Veteran’s home. The primary goals of this pilot research study are to evaluate the feasibility and preliminary functional outcomes of this system in a sample of Veterans with lower limb amputation. Findings from this single-arm pilot study will serve as preliminary data to inform future fully powered clinical trials to assess Mr.MAPP’s efficacy in treating PLP and practical clinical implementation of these findings in real-world settings.

Project Title: A Modified Hub and Spoke Model to Improve Access to MOUD

PI Name: Gregory P. Beehler, PhD, MA; VA Western New York, Center for Integrated Healthcare in Buffalo, NY

Description: This project will evaluate if delivery of medication for opioid use disorder (MOUD) to Veterans has been improved following the implementation of a hub and spoke program (i.e., centralized intakes and inductions with MOUD maintenance managed by referring providers). Based on the RE-AIM framework, VA Corporate Data Warehouse data will be combined with stakeholder interviews to identify system, provider, and patient factors that contributed to program outcomes. Results of this evaluation will suggest if the hub and spoke approach has potential for further adoption in VA to compliment on-going efforts to reduce barriers to MOUD.

Project Title: Development of A Virtual Reality Toolbox for Chronic Pain Self-Management among Veterans

PI Name: Christopher Fowler, PhD; James A. Haley Veterans’ Hospital Tampa, FL

Description: Adjunctive virtual reality (VR) therapies have established efficacy for improving pain-related and functional outcomes. Our team will test a VR ‘toolkit’, which for this study, means that we have identified efficacious VR pain self-management APPs that align with Cognitive-Behavioral Therapy for Chronic Pain (CBT-CP) which will be downloaded onto a VR headset. VR can be a beneficial technology because the Veteran can do this at home and at a time that suits the patient. This will allow us to evaluate Veteran acceptability and tolerance for these different VR APPs prior to feasibility testing our toolkit as a CBT-CP adjunct to help improve adherence and outcomes.

Project Title: VHA Clinician Attitudes and Practices Regarding Buprenorphine Treatment and Impact on Patient Outcomes in Veterans with Opioid Use Disorder

PI Name: Alison (Lewei) Lin, MD; VA Ann Arbor, HSR&D Center for Clinical Management Research, Ann Arbor MI

Description: Increasing buprenorphine treatment and improving retention in care are critical to reducing overdose and other negative outcomes for Veterans with opioid use disorder (OUD). While past work has focused on patient-level factors that contribute to receipt of buprenorphine, we have limited understanding of clinician-level factors and their impact on care delivery, which are particularly salient because there is a wide range of treatment philosophies and practices in buprenoprhine treatment that may also differ across patient characteristics. The overarching goal of this project is to conduct a VHA wide survey study of buprenorphine prescribers to assess clinician attitudes and practices related to buprenorphine treatment using patient vignettes (e.g. to capture different types of patients including those with chronic pain). This understanding of buprenorphine treatment practices will help inform new clinician and system-focused interventions to improve quality of care and outcomes for Veterans with OUD.

Project Title: Understanding primary care experience for homeless-experienced veterans with co-occurring pain and addiction

PI Name: Allyson Varley, PhD, MPH; Birmingham VA Medical Center, Birmingham AL

Description: This study aims to better understand and enhance the primary care experience for Veterans and improve the Homeless Patient Aligned Care Teams (HPACT) service design for those who are experiencing substance use disorder, chronic pain, and homelessness. This study will take advantage of a recently-completed survey of over 3500 Veterans with homeless experience that get their care in HPACTs. We will compare the primary care experiences of Veterans who have chronic pain, substance use disorder, both problems, or neither. We will also compare engagement in pain and addiction health services among Veterans receiving primary care in clinics with higher as opposed to lower patient assessments of care quality.