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PPO 09-281 – HSR&D Study

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PPO 09-281
A Formative Evaluation of a Trial for OEF/OIF Veterans with Chronic Pain
Marianne Sassi Matthias PhD MS BA
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: April 2010 - March 2011

BACKGROUND/RATIONALE:
Chronic pain is a pervasive health problem among OEF/OIF veterans, but there is a paucity of research on how best to treat pain for these veterans. Currently underway is the VA RR&D funded ESCAPE (Evaluation of Stepped Care for Chronic Pain) intervention, a stepped-care intervention for OEF/OIF veterans with chronic pain. This formative evaluation is designed to determine which components of the ESCAPE trial were effective (or ineffective) for pain management and why patients believe them to be so.

OBJECTIVE(S):
This study had three aims.
1. To elicit veterans' views on what is effective/ineffective for treating their chronic pain among the different treatment components of the ESCAPE intervention.

2. To determine whether views of the ESCAPE intervention components elicited in Aim 1 vary based upon veterans' clinical response and adherence to the intervention.

3. To elicit veterans' perceptions of information sharing, support and decision making with their care providers, and whether these perceptions vary based upon patients' response and adherence to the intervention.

METHODS:
We conducted qualitative interviews with veterans who completed ESCAPE. Interview questions related to veterans' experiences with the components of the intervention, their overall perceptions of the intervention, strengths of the trial, suggestions for improvement, and veterans' views of their communication with care providers during the trial. A grounded theory approach, as described by Charmaz, guided qualitative analyses.

FINDINGS/RESULTS:
Twenty-six patients (21% of intervention patients) were interviewed a median of 2 months after trial completion. Patients ranged in age from 24 to 62 (mean = 40); 22 were male. Sixty percent of patients responded to the intervention (defined as a 30% or greater reduction in pain severity); 32% were non-responders. Two patients completed less than 50% of the trial contacts/visits and were classified as non-adherers. Grounded theory analysis revealed the following major themes: 1) Perceptions related to the specific components of the intervention (e.g., cognitive behavioral therapy, self-management strategies, medication optimization, study materials, methods of contact between study team and patients, recommended changes to the intervention); 2) The experience of pain and its effects (e.g., challenges with pain, successes with pain management, effects of pain on activities and relationships, factors influencing pain); 3) Thinking about/"figuring out" pain (e.g., recognizing the relationship between how one feels emotionally and one's experience of pain, learning to manage pain by controlling how one thinks about pain, coping with anxiety and/or depression); 4) Perceptions of social support (e.g., instrumental support from a nurse care manager, such as being held accountable to one's functional goals; emotional support from study personnel; support from family or friends.)

With respect to Aim 1, patients identified cognitive behavioral therapy (CBT) as one of the most helpful parts of the intervention. They described learning how their thoughts and emotions influenced their experience of pain, and how, in turn, they learned to control these thoughts and emotions, leading to better pain control. Self-management strategies and medication management were perceived by many patients to be beneficial. The least helpful component identified was the follow-up phone calls, although some patients found them valuable.

For Aim 2, results showed that responders and non-responders described the intervention similarly, with most delivering favorable assessments. Moreover, preliminary analyses reveal no discernable pattern between responders and non-responders with respect to the different intervention components. CBT was regarded positively by most patients; this held true for responders and non-responders alike. Both groups described the value of learning to adjust their thoughts about their pain, with many commenting that their ability to cope with their pain had improved significantly since participation in the intervention. The same was true for self-management strategies, with members of both responder groups appreciating information sharing, support, and encouragement from the study's nurse care manager about exercises and other self-management strategies. Findings were similar for medication optimization and the follow-up phone calls. Patients critical of some trial elements also comprised both responder groups. We were unable to analyze whether those with low adherence (i.e., completed <50% of the trial) perceived the intervention differently, since we were only able to recruit 2 patients in this category. It is interesting, and merits further analysis, that responders and non-responders had similar perceptions of intervention elements. This suggests that, even if patients do not demonstrate a clinically meaningful response in pain severity, they still may derive benefit, particularly from components such as CBT, which may provide some patients with additional tools to cope more effectively with their pain.

For Aim 3, no overall patterns were discernable with respect to whether responders or non-responders perceived information sharing, support, and decision making with their care providers differently. Most patients described feeling more involved with decisions, better informed, and more supported in their interactions with the study's nurse care manager versus their primary care provider (PCP). Patients were not overly critical of their PCPs, but rather understood that their PCPs manage large panels of patients and thus did not expect their PCPs to have as much time for them as the study's nurse care manager. Additionally, both responders and non-responders held positive views about the phone contacts with the nurse care manager, noting that they enjoyed having one-on-one contact with someone who worked to meet their pain management needs.

IMPACT:
Although OEF/OIF veterans are coming home with an array of injuries resulting in chronic pain, little is known about how best to treat this cohort of veterans. This study, coupled with the ESCAPE trial, will provide valuable information about how to help these veterans manage pain. It is clear from this qualitative study that a multi-component, stepped-care intervention customized to each patient and involving intensive, one-on-one contact, is perceived as helpful by patients and appears to produce positive results with respect to pain management. Once the data are analyzed from the ESCAPE parent trial, we will be able to determine if this holds true for the larger sample. If it does, then the challenge is to determine how such a model (or a similar model) can feasibly be implemented into VA primary care clinics.

PUBLICATIONS:

Journal Articles

  1. Outcalt SD, Nicolaidis C, Bair MJ, Myers LJ, Miech EJ, Matthias MS. A Qualitative Examination of Pain Centrality Among Veterans of Iraq and Afghanistan Conflicts. Pain medicine (Malden, Mass.). 2017 Feb 1; 18(2):211-219.
  2. Matthias MS, Miech EJ, Myers LJ, Sargent C, Bair MJ. A qualitative study of chronic pain in Operation Enduring Freedom/Operation Iraqi Freedom veterans: "A burden on my soul". Military medicine. 2014 Jan 1; 179(1):26-30.
  3. Matthias MS, Parpart AL, Nyland KA, Huffman MA, Stubbs DL, Sargent C, Bair MJ. The patient-provider relationship in chronic pain care: providers' perspectives. Pain medicine (Malden, Mass.). 2010 Nov 1; 11(11):1688-97.
Journal Other

  1. Miech EJ, Sternke EA, Myers L, Bair MJ, Matthias MS. "There’s more to this pain than just pain": How patients understand the management of chronic pain. [Abstract]. Journal of general internal medicine. 2011 Jun 1; 26(S1):S73.
Conference Presentations

  1. Matthias MS, Miech EJ, Sternke EA, Myers L, Bair MJ, Sargent C. "There’s more to this pain than just pain": How patients understand the management of chronic pain. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 4; Phoenix, AZ.


DRA: Acute and Combat-Related Injury
DRE: Treatment - Observational
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom, Outcomes - Patient, Pain
MeSH Terms: none

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