Chronic pain is prevalent and costly, affecting at least 116 million Americans and amounting to over $630 billion annually in direct medical costs and lost worker productivity. Even more concerning, pain is a considerable problem among veterans, particularly those returning from service in Iraq and Afghanistan. Up to 58% of these veterans are returning home with pain. Self-management is an evidence-based treatment for chronic pain. However, self-management programs are not consistently employed in VA because of numerous implementation barriers, including lack of provider time to deliver such interventions. A promising and innovative approach to help overcome barriers to implementing a self-management program in VA is peer-delivery-with veterans who have successfully completed a pain self-management education program serving as peers. We are partnering with the VA National Pain Management Program Office, directed by Dr. Robert Kerns, to test peer delivery of pain self-management.
The IMPPRESS RRP (IMproving Pain using Peer RE-inforced Self-management Skills) is a pilot study that is a formative evaluation of peer delivery of pain self-management to patients with chronic musculoskeletal pain. Guided by the RE-AIM framework, this study has 3 aims: 1) Evaluate the feasibility of identifying, recruiting, and training veteran peers to implement a self-management program for chronic pain; 2) Identify facilitators and barriers to peer-delivery of a chronic pain self-management program; 3) Convene an expert panel to review the results of Aims 1 and 2, help to interpret the results, and plan next steps.
We recruited 30 veterans from Roudebush VAMC: 10 to serve as peers, 20 as patients. Peers will be assigned 2 patients each. All participants had chronic musculoskeletal pain. All peeers were recruited from a pool of patients who completed a pain self-management program in a previous study at Roudebush VAMC. Peers were trained in how to deliver self-management instruction and how to be a peer. Patients received two phases of self-management instruction: Phase 1 was a single session delivered by a nurse care manager, and Phase 2 was delivered over 4 months by the peers. Peers were supervised by a clinical psychologist (Dr. Kukla) who met with them regularly and provide support, information, and any other assistance. For Aim 1, the study team tracked peer recruitment rates, retention of peers, and reasons for refusal. In addition, we measured self-efficacy, pain intensity, pain interference, patient activation, negative pain cognitions (pain centrality and pain catastrophizing), depression, anxiety, and social support at baseline and 4-month follow-up. At the 4-month follow-up, all participants were interviewed to understand facilitators and barriers to peer supported pain self-management (Aim 2). Data analysis for outcomes measured in aim 1, a linear mixed model with a random effect for peers was applied, to assess changes in outcomes from baseline to 4-month follow-up. For aim 2, an immersion/crystallization approach to qualitative data analysis is being used. Aim 2 analyses are ongoing.
Aim 1: All participants were recruited in the first two months of the study. Of peers, 16 declined. Of patients, 48 declined to participate. Most common reasons were not having enough time to participate. Training was successfully conducted for peers in 3 separate sessions co-taught by the study psychologist and study nurse. Patient self-management training (phase 1) was successfully conducted in 4 separate sessions taught by the study nurse. Retention was high for both peers and patients, with 9 of 10 peers who started the intervention completing (90% retention rate) and 17 of 20 patients completing (85% retention rate).
Aim 2: In the effort to identify facilitators and barriers, we also measured intervention effectiveness, since there is limited work on peer support in pain self-management. Patients improved on all measures, though we did not have enough statistical power to detect significant change. Of particular interest, however, are the effect sizes for self-efficacy (Cohen's d=.60), patient activation (Cohen's d=.49), and centrality of pain (Cohen's d=-.62). These findings indicate that, from an effectiveness standpoint, peer-supported pain self-management is a promising approach to treating Veterans with chronic pain. Qualitative interviews are still being analyzed, but initial results reveal that Veterans felt that they benefitted greatly from the intervention. The following themes (facilitators) emerged in the Veteran interviews: having someone with similar problems to talk to, sharing experiences (including Veteran identity), learning new self-management strategies, help with coping with pain, and getting practical support from their peer (e.g., advice on how to get a scooter through VA). For peers, four main themes emerged: fostering interpersonal connections, putting their own problems in perspective, gaining a sense of satisfaction from helping others, and strengthening/reinforcing their own self-management practices. Barriers are still being analyzed, but one that emerged early in the intervention was difficulty with initial start-up/engagement. Veteran-peer pairs sometimes had trouble connecting with a first meeting and/or gaining momentum to meet regularly. It seemed that many pairs had just gotten into a rhythm when the intervention was drawing to a close, suggesting that a longer intervention period might be more appropriate.
Aim 3: Next steps. IMPPRESS helped to establish the feasibility of a peer-support program for pain self-management. Recruitment and training went relatively smoothly, retention was high, and participants were generally very satisfied with the intervention. Also encouraging was that Veterans improved on measures of pain intensity and interference, self-management self-efficacy, and measures of coping. IMPPRESS has been instrumental in leading to the next step, which is an IIR that was submitted to HSR&D in December 2013, Evaluation of a Coach-Led Intervention for Pain Self-Management (ECLIPSE, PI: Dr. Matthias).
Chronic pain is prevalent among Veterans, and pain self-management is an evidence-based practice advocated by VHA and the Institute of Medicine. However, personalized, one-on-one pain self-management instruction and support is unfeasible for VA clinicians to provide. A peer support model of pain self-management, not unlike the peer specialist model used in VA mental health services, is a promising approach to provide more Veterans with pain self-management instruction and support/encouragement. IMPPRESS demonstrated that such a model is feasible and acceptable to Veterans, and we have preliminary indication that pain self-management is still effective when delivered through peers rather than clinicians. Although we plan to test this in a large trial (Hybrid Type 1 design), a model of peer support for pain self-management is a promising treatment for Veterans with chronic pain.
- Bauer SM, McGuire AB, Kukla M, McGuire S, Bair MJ, Matthias MS. Veterans' pain management goals: Changes during the course of a peer-led pain self-management program. Patient education and counseling. 2016 Dec 1; 99(12):2080-2086.
- Matthias MS, Kukla M, McGuire AB, Bair MJ. How Do Patients with Chronic Pain Benefit from a Peer-Supported Pain Self-Management Intervention? A Qualitative Investigation. Pain medicine (Malden, Mass.). 2016 Dec 1; 17(12):2247-2255.
- Matthias MS, Kukla M, McGuire AB, Damush TM, Gill N, Bair MJ. Facilitators and Barriers to Participation in a Peer Support Intervention for Veterans With Chronic Pain. The Clinical Journal of Pain. 2016 Jun 1; 32(6):534-40.
- Matthias MS, McGuire AB, Kukla M, Daggy J, Myers LJ, Bair MJ. A brief peer support intervention for veterans with chronic musculoskeletal pain: a pilot study of feasibility and effectiveness. Pain medicine (Malden, Mass.). 2015 Jan 1; 16(1):81-7.
- Matthias MS, Kukla ME, McGuire AB, Bair MJ. Peer support for chronic pain self-management: A qualitative study of peer coaches' experiences. [Abstract]. Journal of general internal medicine. 2014 Apr 16; 29(1):169-170.
- Matthias MS, McGuire AB, Kukla ME, Daggy J, Myers L, Bair MJ. Effectiveness of a brief peer support intervention for veterans with chronic pain. [Abstract]. Journal of general internal medicine. 2014 Apr 16; 29(1):80.
- Matthias MS, Kukla ME, McGuire AB, Bair MJ. Facilitators and barriers to peer support for chronic pain self-management in Veterans. Poster session presented at: American Pain Society Annual Meeting; 2015 May 13; Palm Springs, CA.
- Matthias MS, Kukla ME, McGuire AB, Bair MJ. Peer support for chronic pain self-management: A qualitative study of peer coaches' experiences. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 23; San Diego, CA.
- Matthias MS, McGuire AB, Kukla ME, Daggy J, Myers L, Bair MJ. Effectiveness of a brief peer support intervention for Veterans with chronic pain. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 23; San Diego, CA.
Treatment - Efficacy/Effectiveness Clinical Trial