September 2021

In This Issue: Helping Veterans Cope with and Conquer Pain
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Preventing Chronic Post-Surgical Pain and Prolonged Opioid Use

Feature Article

Takeaway: This study is expected to enhance biopsychosocial pain care during the perioperative period for Veterans – and offers a model to prevent the development of chronic pain and prolonged opioid use following surgery. The proposed innovative approach to preventing, rather than managing chronic post-surgical pain among Veterans could incite a clinical paradigm shift from pain treatment to prevention.

Surgery can precipitate the development of both chronic pain and long-term opioid use. Preoperative psychological distress is a risk factor for poor post-surgical outcomes. Strategies are needed to augment perioperative pharmacotherapeutic management of pain with non-pharmacologic strategies to optimize postoperative outcomes. Psychological interventions such as cognitive behavioral therapy (CBT) can effectively reduce distress and improve functioning among patients with chronic pain. While CBT has been used extensively in patients with established chronic pain, it has not been used as a preventive intervention targeting the transition from acute to chronic post-surgical pain.

This ongoing study (August 2021 – July 2025) will examine the efficacy of the Perioperative Pain Self-management (PePS) program versus Standard Care (SC) for preventing chronic postoperative pain and prolonged opioid use among 400 Veterans scheduled for unilateral primary total joint arthroplasty at the Iowa City or Minneapolis VA Medical Centers. Exploratory analyses will examine whether substance use disorders moderate treatment effects – and whether changes in pain catastrophizing and self-efficacy relate to postoperative pain at six-months post-surgery. Investigators also aim to:

• Determine the impact of the PePS program on secondary outcomes such as mood, functioning, and non-opioid analgesic prescriptions; and
• Evaluate the context of implementation by examining acceptability, feasibility, and appropriateness among Veterans and care team members.

The primary outcome (surgical site pain) will be assessed at six-months post-surgery. The secondary outcome – time to postoperative opioid cessation – will be assessed for the first six weeks following surgery. All other secondary outcomes (mood and pain-related functioning) will be assessed at six-months post-surgery.

Methodology

This study is a hybrid efficacy-implementation designed to facilitate a more rapid move toward broad-based dissemination and uptake of the PePS program. Investigators will use a single-blind, two-arm, parallel, randomized control trial. Veterans in this study will be randomized to PePS or SC. The PePS program includes four telephone sessions: Session one is preoperative and includes an introduction to relaxation and the importance of interpretation in the pain experience. Session two (two weeks postop) consists of a review of relaxation and the connection between thoughts/interpretation and pain, and an introduction to thought records. Session three includes a review of thought records and relaxation and an introduction to goal-setting and cognitive restructuring. Session four consists of a review in addition to creating a plan for the continued use of new skills. In addition, study investigators will conduct qualitative interviews with both Veteran surgical patients and surgery clinic staff (surgeons, nurses, and clerks) at both VAMCs.

Findings

No findings to report at this time.

Anticipated Impact

This study enhances biopsychosocial pain care during the perioperative period and offers a model to prevent the development of chronic pain and prolonged opioid use following surgery. The proposed innovative approach to preventing, rather than managing, chronic postsurgical pain among Veterans could incite a clinical paradigm shift from pain treatment to prevention.

Principal Investigators

Katherine Hadlandsmyth, PhD, and Hilary Mosher, MD, are investigators with HSR&D’s Center for Access & Delivery Research and Evaluation (CADRE) in Iowa City, IA.

Publications

Hadlandsmyth K, Conrad M, Steffensmeier K, et al. Enhancing the biopsychosocial approach to perioperative care: A randomized pilot trial of the Perioperative Pain Self-management (PePS) program among rural-dwelling Veterans. Annals of Surgery. December 18, 2020; online ahead of print.

View study abstract