Improving Access to Evidence-Based Non-Pharmacologic Pain Care in VA

HSR&D’s monthly publication Veterans’ Perspectives highlights research conducted by QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research.

In the September 2018 Issue:

IMPROVE QUERI and the Cooperative Pain Education and Self-management Program

• Introduction
• Veterans' Perspective
• Current Efforts to Expand Access to COPES in VA

Introduction

Chronic pain has wide-ranging effects including interference with physical and emotional functioning, sleep, and quality of life. Cognitive behavioral therapy (CBT) focuses on the relationship among thoughts, emotions, and behaviors – and can be delivered alone or as part of an integrated pain management program. CBT for chronic pain (CBT-CP) is an evidence-based treatment that can reduce pain and associated disability and distress, and CBT-CP has been adopted as a first-line non-pharmacological therapy in the VA healthcare system.¹ CBT can also reduce reliance on the overuse of opioids, which is vital to both Veterans and the general public. However, barriers to accessing CBT-CP persist. CBT-CP treatment requires multiple in-person visits and highly trained staff, and many Veterans receive care in facilities where these services are not available.  

To expand access to CBT-CP, investigators with HSR&D’s Improving Pain-Related Outcomes for Veterans (IMPROVE) QUERI developed and evaluated the “Cooperative Pain Education and Self-management” or COPES program. COPES uses interactive voice response (IVR) technology to allow Veterans to participate in treatment from their homes, with no in-person visits required. Using an automated telephone system, the 125 participants in the trial answered daily questions about their pain intensity, number of steps, practice of the pain management skills, and sleep quality. At the end of each week, a therapist reviewed the information and recorded a personalized feedback message for the participant to listen to on their phone. The feedback messages were designed to mimic treatment sessions by reinforcing skill practice and steps, troubleshooting when it seemed participants were not meeting goals, and summarizing their progress over the past week – and relative to the beginning of treatment. 

Led by Principal Investigator Dr. Alicia Heapy and Co-Principal Investigator Dr. John Piette, researchers evaluated the effectiveness of COPES relative to standard in-person CBT-CP in a comparative effectiveness randomized trial.

Alicia Heapy, PhD

John Piette, PhD, MSc

Results of their study showed that patients with chronic pain in COPES did just as well as those receiving in-person treatment and reported improvements in physical functioning, sleep, and pain.² COPES patients also set goals for daily walking and, by end of treatment, were able to increase their average steps by 2,000 steps per day.  

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Veterans' Perspective

In interviews conducted after the COPES study, Veterans said they enjoyed the program and thought it helped them manage their pain. Some Veterans talked about their favorite skills:

“Pacing. By going through this study I was like, “you know, I really should do this more, not try to push through and do everything at once. Do it in stages”. And, “I would find myself just getting stuck in a certain mindset. And I’d say “Wait a minute! You can talk yourself out of this.” You can breathe, do the relaxation, refocus.”

Others said that the program helped them think about their pain differently:

“When my friend would say “I thought you were in pain?” I’m like, “Well yes, I am in pain, I was in pain, but I am just able to work with it more.” And “Don’t let your life be about the pain. You may never be completely out of pain, but you can learn to live with it.”

Veteran Engagement Group members

Veteran Engagement Group members

Interviews with COPES patients and with Veterans who are part of the Veteran Engagement Group at HSR&D’s Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation have provided additional information about barriers to engaging in CBT-CP generally.

Veterans told QUERI investigators that they were not sure what CBT-CP was or how a psychological intervention could help them manage their physical complaints. The also noted that they would be more likely to try CBT-CP if they heard about another Veteran’s positive experience with it. In addition, they wanted to learn more about the pain management skills prior to starting.

Sample: COPES Patient Q&A

Q: Was there anything about the program that you didn’t expect?
A: Yes, It’s effects.  I didn’t expect it to work as well as it did. My pain reduced.
A: I had not expected homework, which I greatly loved. The program kept me on point and focused and helped me to set and keep goals in my everyday life

Q: What did you like best?
A: It allowed me to plan meaningful goals and has helped me put more tools in my tool box for pain management and goals in my everyday life. I wished the program would be longer.
A: I liked the connection I had with Dana (my coach). Good feedback.

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Current efforts to expand access to COPES in VA

Based on the success of the first COPES trial, QUERI investigators began a new study designed to build on the program’s strengths and to address the barriers to program dissemination. The study is being conducted among Veterans with chronic musculoskeletal pain who get their care in community-based outpatient clinics (CBOCs) where access to specialty pain management services including CBT-CP is often especially difficult.  The study, called COPES Implementation, is being conducted at five community-based outpatient clinics (CBOCs) affiliated with VA Boston.  The study has three goals:

• Test strategies for increasing Veteran participation in and provider referral to COPES,
• Understand the barriers and facilitators to providing CBT-CP generally and COPES specifically, and
• Evaluate COPES-related patient outcomes including functioning and use of other VA services.

This project is part of the IMPROVE QUERI program. In collaboration with the VHA Pain Management and Primary Care Services (PCS), IMPROVE QUERI is conducting several studies to evaluate the use of non-pharmacological treatments to increase the safety and efficacy of pain care regimens. The information gained will be used to inform care and policy decisions. 

In response to Veterans’ feedback regarding the importance of hearing from other COPES patients, investigators have begun to produce brief videos with Veterans’ testimonials about their positive experience with CBT-CP and COPES and brief explainers about what CBT-CP is, how it can help manage pain, and CBT-CP skill demonstrations. These videos will be available online and scannable from our study recruitment posters in spring 2019. Providers stated that they would like to have short scripts for recommending CBT-CP to patients, so investigators also are developing short video explainers for how to present CBT-CP in a brief manner.

The COPES implementation study will inform care and policy decisions in VA related to a wider rollout of the COPES program. The videos developed in this trial will be used to promote engagement in current and future studies and will be made available on the VHA Pain Management website. Developing methods to increase access to CBT-CP and ease barriers to provider referral and patient engagement are critical aspects of promoting multi-modal pain treatment and facilitating patient self-management.

For more information about COPES Implementation or the IMPROVE QUERI program, please contact Alicia Heapy, PhD at alicia.heapy@va.gov  or John Piette, PhD at john.piette@va.gov or jpiette@med.umich.edu.

1. Becker W, DeBar L, Heapy A, et al. A research agenda for advancing non-pharmacological management of chronic musculoskeletal pain: Findings from a VHA state-of-the-art conference. Journal of General Internal Medicine. May 2018;33(Suppl 1):11-15.
2. Heapy A, Higgins D, Driscoll M, et al. Cooperative pain education and self-management (COPES): A non-inferiority trial of an interactive voice response-based self-management intervention for chronic back pain: The COPES Non-inferiority Randomized Trial. JAMA Internal Medicine. June 2017;177(6):765-773.

*Located in West Haven, CT and Palo Alto, CA, HSR&D’s IMPROVE QUERI program works to improve function and quality of life – and to decrease morbidity and mortality among Veterans with chronic pain.

*Located in West Haven, CT, HSR&D’s PRIME Center of Innovation studies the interactions between pain and associated chronic conditions and behavioral health factors, which will help VA develop and implement effective interventions that can reduce pain.

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