Integrated, Team-Based Chronic Pain Management: Bridges from Theory and Research to High Quality Patient Care

Chronic pain is a significant public health concern. For many, chronic pain is associated with declines in physical functioning and increases in emotional distress. Additionally, the socioeconomic burden associated with costs of care, lost wages and declines in productivity are significant. A large and growing body of research continues to support the biopsychosocial model as the predominant framework for conceptualizing the experience of chronic pain and its multiple negative impacts. The model also informs a widely accepted and empirically supported approach for the optimal management of chronic pain. This chapter briefly articulates the historical foundations of the biopsychosocial model of chronic pain followed by a relatively detailed discussion of an empirically informed, integrated, multimodal and interdisciplinary treatment approach. The role of mental health professionals, especially psychologists, in the management of chronic pain is particularly highlighted.

Interactive Voice Response-Based Self-management for Chronic Back Pain: The COPES Noninferiority Randomized Trial

IMPORTANCE

Recommendations for chronic pain treatment emphasize multimodal approaches, including nonpharmacologic interventions to enhance self-management. Cognitive behavioral therapy (CBT) is an evidence-based treatment that facilitates management of chronic pain and improves outcomes, but access barriers persist. Cognitive behavioral therapy delivery assisted by health technology can obviate the need for in-person visits, but the effectiveness of this alternative to standard therapy is unknown. The Cooperative Pain Education and Self-management (COPES) trial was a randomized, noninferiority trial comparing IVR-CBT to in-person CBT for patients with chronic back pain.

OBJECTIVE

To assess the efficacy of interactive voice response-based CBT (IVR-CBT) relative to in-person CBT for chronic back pain.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a noninferiority randomized trial in 1 Department of Veterans Affairs (VA) health care system. A total of 125 patients with chronic back pain were equally allocated to IVR-CBT (n = 62) or in-person CBT (n = 63).

INTERVENTIONS

Patients treated with IVR-CBT received a self-help manual and weekly prerecorded therapist feedback based on their IVR-reported activity, coping skill practice, and pain outcomes. In-person CBT included weekly, individual CBT sessions with a therapist. Participants in both conditions received IVR monitoring of pain, sleep, activity levels, and pain coping skill practice during treatment.

MAIN OUTCOMES AND MEASURES

The primary outcome was change from baseline to 3 months in unblinded patient report of average pain intensity measured by the Numeric Rating Scale (NRS). Secondary outcomes included changes in pain-related interference, physical and emotional functioning, sleep quality, and quality of life at 3, 6, and 9 months. We also examined treatment retention.

RESULTS

Of the 125 patients (97 men, 28 women; mean [SD] age, 57.9 [11.6] years), the adjusted average reduction in NRS with IVR-CBT (-0.77) was similar to in-person CBT (-0.84), with the 95% CI for the difference between groups (-0.67 to 0.80) falling below the prespecified noninferiority margin of 1 indicating IVR-CBT is noninferior. Fifty-four patients randomized to IVR-CBT and 50 randomized to in-person CBT were included in the analysis of the primary outcome. Statistically significant improvements in physical functioning, sleep quality, and physical quality of life at 3 months relative to baseline occurred in both treatments, with no advantage for either treatment. Treatment dropout was lower in IVR-CBT with patients completing on average 2.3 (95% CI, 1.0-3.6) more sessions.

CONCLUSIONS AND RELEVANCE

IVR-CBT is a low-burden alternative that can increase access to CBT for chronic pain and shows promise as a nonpharmacologic treatment option for chronic pain, with outcomes that are not inferior to in-person CBT.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01025752.

Association of Pain With Physical Function, Depressive Symptoms, Fatigue, and Sleep Quality Among Veteran and non-Veteran Postmenopausal Women

PURPOSE OF STUDY

To characterize the prevalence and longitudinal effects of pain in older Veteran and non-Veteran women.

DESIGN AND METHODS

Data on 144,956 participants in the Women's Health Initiative were analyzed. At baseline, Veteran status, pain severity, and pain interference with activity were assessed. Outcomes of physical function, depressive symptoms, fatigue, and sleep quality were reported at baseline by all study participants and longitudinally on two follow-up occasions (3 years and 13-18 years after baseline) in the observational study participants (n = 87,336).

RESULTS

At baseline, a total of 3,687 (2.5%) had a history of military service and 22,813 (15.8%) reported that pain limited their activity level moderately to extremely during the past 4 weeks. Prevalence of pain interference did not differ in Veterans and non-Veterans (16.8% and 15.7%, respectively; p= .09). At baseline, women with moderate-to-extreme pain interference had substantially worse physical function and greater symptoms of depression, fatigue, and insomnia than those with less pain (p < .001 for all comparisons), adjusting for several social, behavioral, and health related factors. There were no significant military service by pain interference interactions for any of the outcomes (p > .2), indicating that the effect of pain interference on outcomes at baseline did not vary between Veterans and non-Veterans. Moderate-to-extreme pain interference was associated with a greater rate of decline in physical function over time (p < .001) and higher incidence of limited physical functioning (p < .001), but these effects did not vary by Veteran status. Similar results were observed with pain severity as the exposure variable.

IMPLICATIONS

As the Veteran population ages and the number of women exposed to combat operations grows, there will be an increased need for health care services that address not only pain severity and interference but also other disabling comorbid symptoms.

Taking ACTION to reduce pain: ACTION study rationale, design and protocol of a randomized trial of a proactive telephone-based coaching intervention for chronic musculoskeletal pain among African Americans

Background

Rates of chronic pain are rising sharply in the United States and worldwide. Presently, there is evidence of racial disparities in pain treatment and treatment outcomes in the United States but few interventions designed to address these disparities. There is growing consensus that chronic musculoskeletal pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental factors, some of which differ by race.

Methods/Design

The primary aim of this randomized controlled trial is to test the effectiveness of a non-pharmacological, self-regulatory intervention, administered proactively by telephone, at improving pain outcomes and increasing walking among African American patients with hip, back and knee pain. Participants assigned to the intervention will receive a telephone counselor delivered pedometer-mediated walking intervention that incorporates action planning and motivational interviewing. The intervention will consist of 6 telephone counseling sessions over an 8–10 week period. Participants randomly assigned to Usual Care will receive an informational brochure and a pedometer. The primary outcome is chronic pain-related physical functioning, assessed at 6 months, by the revised Roland and Morris Disability Questionnaire, a measure recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). We will also examine whether the intervention improves other IMMPACT-recommended domains (pain intensity, emotional functioning, and ratings of overall improvement). Secondary objectives include examining whether the intervention reduces health care service utilization and use of opioid analgesics and whether key contributors to racial/ethnic disparities targeted by the intervention mediate improvement in chronic pain outcomes Measures will be assessed by mail and phone surveys at baseline, three months, and six months. Data analysis of primary aims will follow intent-to-treat methodology.

Discussion

We will tailor our intervention to address key contributors to racial pain disparities and examine the effects of the intervention on important pain treatment outcomes for African Americans with chronic musculoskeletal pain.

Trial registration

ClinicalTrials.gov: NCT01983228. Registered 6 November 2013.

Classifying Clinical Notes with Pain Assessment

Pain is a significant public health problem, affecting an estimated 100 million Americans. Evidence has highlighted that patients with chronic pain often suffer from deficits in pain care quality (PCQ). Efforts to improve PCQ hinge on the identification of reliable PCQ indicators such as pain assessment. In this study, we developed a classifier that leverages narratives in clinical notes to derive indicators of pain assessment for patients with chronic pain.

National Action Plan for Adverse Drug Event Prevention: Recommendations for Safer Outpatient Opioid Use

INTRODUCTION

Adverse drug events (ADEs) have been highlighted as a major patient safety and public health challenge by the National Action Plan for Adverse Drug Event Prevention (ADE Action Plan), which was released by the Office of Disease Prevention and Health Promotion (ODPHP) in August 2014. The ADE Action Plan focuses on surveillance, evidence-based prevention, incentives, and oversights, additional research needs as well as possible measures and metrics to track progress of ADE prevention within three drug classes: anticoagulants, diabetes agents, and opioids.Objectives and Recommendations. With outpatient opioid prescriptions being a great concern among many healthcare providers, this article focuses on recommendations from the ADE Action Plan to help guide safer opioid use in healthcare delivery settings. Its aim is to discuss current federal methods in place to prevent opioid ADEs while also providing evidence to encourage providers and hospitals to innovate new systems and practices to increase prevention.

Combined Use of Opioids and Antidepressants in the Treatment of Pain: A Review of Veterans Health Administration Data for Patients with Pain Both With and Without Co-morbid Depression

Musculoskeletal pain is prevalent among Veterans treated within the Veterans Health Administration (VHA). Depression is highly co-prevalent, and antidepressants are increasingly being used for psychiatric and analgesic benefit. The current study examined prescribing patterns of antidepressants and opioids in the context of musculoskeletal pain using a national VHA database. All Veterans diagnosed with musculoskeletal pain who attended at least one appointment through the VHA during Fiscal Year 2012 were dichotomized based on the presence or absence of a depression diagnosis. We compared the proportion in each group that were prescribed antidepressants to the entire sample and repeated this comparison along a continuum of the number of annual opioid prescriptions received (ranging in five categories from no opioids up to >20 scripts). Of the 5.1 million Veterans seen, 19.1 % were diagnosed with musculoskeletal pain, of whom, 27.2 % were diagnosed with major depressive disorder. Antidepressants were prescribed to 78.41 % of patients with musculoskeletal pain and depression, compared to 20.23 % of those without depression. For both groups, antidepressant use increased linearly as annual opioid fills increased. Across the categories of opioid use, patients with depression showed a 13.98 % increase in antidepressant use, compared to a 33.97 % increase in the non-depressed group. Results suggest that antidepressants are frequently prescribed to patients with musculoskeletal pain who are using opioids, consistent with multi-modal pharmacotherapy. Increasing use of antidepressants in conjunction with escalating opioid prescribing, particularly in the absence of diagnosed depression, suggests that antidepressants are being used in both groups to complement opioid therapy.

Improving pain care through implementation of the Stepped Care Model at a multisite community health center

PURPOSE

Treating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center.

METHODS

The Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 preintervention and 4,385 postintervention) cared for at Community Health Center, Inc. Data were collected from the electronic health record and supplemented by chart reviews. Surveys were administered to PCPs to assess knowledge, attitudes, and confidence.

RESULTS

Providers' pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing.

CONCLUSION

Implementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes.

Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study

AIMS

To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care.

DESIGN

Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use.

SETTING

Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC.

PARTICIPANTS

A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012.

MEASUREMENTS

The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use.

FINDINGS

Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35].

CONCLUSIONS

New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.

Communicating diagnostic certainty of psychogenic nonepileptic seizures - a national study of provider documentation

Management of psychogenic nonepileptic seizures (PNES) requires collaboration among and between health care professionals. Although criteria are established for diagnosis of PNES, miscommunication between neurologists, primary care providers, and mental health professionals may occur if the clinical impression is not clearly articulated. We extracted progress notes from the Department of Veterans Affairs (VA) electronic health record (EHR) nationally to study veterans who were evaluated for PNES. Of the 750 patients being worked up for PNES, the majority of patients did not meet criteria for PNES (64.6%). Of those who were thought to suffer from PNES, 147 (19.6%) met International League Against Epilepsy (ILAE) criteria for documented PNES, 14 (1.9%) for clinically established PNES, and 104 (13.9%) for probable or possible PNES. Neurologists tended to use ambiguous language, such as "thought to be" or "suggestive of" to describe their impressions of patients overall, even those with definitive PNES. Ambiguous language may lead to miscommunication across providers and inappropriate health care.

Psychiatric Disorders Among Patients Seeking Treatment for Co-Occurring Chronic Pain and Opioid Use Disorder

OBJECTIVE

Psychiatric comorbidities complicate treatment of patients with chronic pain and opioid use disorder, but the prevalence of specific comorbid psychiatric disorders in this population has not been systematically investigated.

METHODS

170 consecutive participants entering a treatment research program for co-occurring chronic pain and opioid use disorder between March 2009 and July 2013 were evaluated with the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I/P) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV).

RESULTS

The prevalence of any lifetime (and current) comorbid Axis I disorder was 91% (75%); 52% met criteria for lifetime anxiety disorder (48% current), 57% for lifetime mood disorder (48% current), and 78% for lifetime nonopioid substance use disorder (34% current). Common current anxiety diagnoses were posttraumatic stress disorder (21%), generalized anxiety disorder (16%), and panic disorder without agoraphobia (16%). Common current mood diagnoses were major depressive disorder (40%) and dysthymia (11%). A majority of patients had a personality disorder (52%).

CONCLUSIONS

High rates and persistence of co-occurring psychiatric disorders, including anxiety or mood disorders, may explain in part the difficulty providers have treating patients with co-occurring opioid use disorder and chronic pain and suggest possible targets for improving treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: buprenorphine/naloxone treatment (NCT00634803), opioid treatment program-based methadone maintenance treatment (NCT00727675).

Prevalence and correlates of coprescribing anxiolytic medications with extensive prescription opioid use in Veterans Health Administration patients with metastatic cancer

OBJECTIVE

To examine the prevalence and correlates of concomitant anxiolytic prescription fills in Veterans Health Administration (VHA) patients with metastatic cancer who have extensive prescription opioid use.

DESIGN, SETTING, AND PARTICIPANTS

National VHA data for fiscal year 2012 were used to identify veterans diagnosed with metastatic cancer (ICD-9 codes 196-199) who also had extensive prescription opioid use (at least 10 opioid prescriptions during the year, comprising the highest 29 percent of opioid users). Bivariate and multivariate analyses were used to examine correlates of receiving anxiolytic medication among veterans with metastatic cancer and extensive prescription opioid use.

RESULTS

Of the 5,950 veterans with metastatic cancer and extensive prescription opioid use, 51 percent also received anxiolytic medication, of whom 64 percent had a medical indication and 85 percent had a psychiatric or medical indication for psychotropics. Of those with extensive prescription opioid use who filled an anxiolytic, 64 percent also received antidepressants and 38 percent received three or more classes of psychotropic medication (ie, polypharmacy). In multivariate analyses, factors associated with receipt of an anxiolytic included any anxiety disorder, insomnia, the prescription of antidepressants or antipsychotics, bipolar disorder, younger age, more emergency department visits, and greater number of opioid prescriptions.

CONCLUSIONS

VHA patients with metastatic cancer and extensive prescription opioid use who are prescribed anxiolytics are likely to have a Food and Drug Administration-approved indication for psychotropics, and anxiolytics in particular, but represent a clinically vulnerable group which merits careful monitoring.

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

PURPOSE

For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality.

METHODS

Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality.

RESULTS

Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67).

CONCLUSIONS

Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.

Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools: Protocol for a Randomized Study Funded by the US Department of Veterans Affairs Health Services Research and Development Program

BACKGROUND

Cognitive behavioral therapy (CBT) is one of the most effective treatments for chronic low back pain. However, only half of Department of Veterans Affairs (VA) patients have access to trained CBT therapists, and program expansion is costly. CBT typically consists of 10 weekly hour-long sessions. However, some patients improve after the first few sessions while others need more extensive contact.

OBJECTIVE

We are applying principles from "reinforcement learning" (a field of artificial intelligence or AI) to develop an evidence-based, personalized CBT pain management service that automatically adapts to each patient's unique and changing needs (AI-CBT). AI-CBT uses feedback from patients about their progress in pain-related functioning measured daily via pedometer step counts to automatically personalize the intensity and type of patient support. The specific aims of the study are to (1) demonstrate that AI-CBT has pain-related outcomes equivalent to standard telephone CBT, (2) document that AI-CBT achieves these outcomes with more efficient use of clinician resources, and (3) demonstrate the intervention's impact on proximal outcomes associated with treatment response, including program engagement, pain management skill acquisition, and patients' likelihood of dropout.

METHODS

In total, 320 patients with chronic low back pain will be recruited from 2 VA healthcare systems and randomized to a standard 10 sessions of telephone CBT versus AI-CBT. All patients will begin with weekly hour-long telephone counseling, but for patients in the AI-CBT group, those who demonstrate a significant treatment response will be stepped down through less resource-intensive alternatives including: (1) 15-minute contacts with a therapist, and (2) CBT clinician feedback provided via interactive voice response calls (IVR). The AI engine will learn what works best in terms of patients' personally tailored treatment plans based on daily feedback via IVR about their pedometer-measured step counts, CBT skill practice, and physical functioning. Outcomes will be measured at 3 and 6 months post recruitment and will include pain-related interference, treatment satisfaction, and treatment dropout. Our primary hypothesis is that AI-CBT will result in pain-related functional outcomes that are at least as good as the standard approach, and that by scaling back the intensity of contact that is not associated with additional gains in pain control, the AI-CBT approach will be significantly less costly in terms of therapy time.

RESULTS

The trial is currently in the start-up phase. Patient enrollment will begin in the fall of 2016 and results of the trial will be available in the winter of 2019.

CONCLUSIONS

This study will evaluate an intervention that increases patients' access to effective CBT pain management services while allowing health systems to maximize program expansion given constrained resources.

Stepped care model of pain management and quality of pain care in long-term opioid therapy

Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.

Initial development of patient-reported instrument assessing harm, efficacy, and misuse of long-term opioid therapy

Guidelines on long-term opioid therapy recommend frequent reassessment of harm, efficacy, and misuse of these potentially harmful and sometimes ineffective medications. In primary care, there is a need for a brief, patient-reported instrument. This report details the initial steps in the development of such an instrument. An interdisciplinary team of clinician-scientists performed four discrete steps in this study: (1) conceptualization of the purpose and function of the instrument, (2) assembly of an item pool, (3) expert rating on which items were most important to include in the instrument, and (4) modification of expert-selected items based on a reading level check and cognitive interviews with patients. A diverse panel of 47 subject matter experts was presented with 69 items to rate on a 1-9 scale in terms of importance for inclusion in the instrument. The panel highly rated 37 items: 8 related to harm, 4 related to efficacy, and 25 related to misuse. These 37 items were then tested for patient comprehension and modified as needed. Next steps in development will include further item reduction, testing against a gold standard, and assessment of the instrument's effect on clinical outcomes.

Trends in Any and High-Dose Opioid Analgesic Receipt Among Aging Patients With and Without HIV

Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need for appropriate balance of risks and benefits, especially as these populations age.

Cooperative pain education and self-management (COPES): study design and protocol of a randomized non-inferiority trial of an interactive voice response-based self-management intervention for chronic low back pain

Background

The Institute of Medicine report “Relieving Pain in America” recommends the promotion of patient self-management of pain for all people with pain. Given the high prevalence of chronic pain in the US, new strategies are needed to enhance access to cognitive behavioral therapy (CBT) and other evidence-based treatments designed to facilitate self-management of chronic pain conditions. Although CBT is efficacious, many patients have limited or no access to CBT. Technology-assisted delivery of CBT may improve access while maintaining efficacy.

Methods/Design

We describe a randomized non-inferiority trial of interactive voice response (IVR)-based CBT for patients with chronic low back pain. This intervention uses daily IVR monitoring and weekly pre-recorded therapist feedback, based on patient-reported information, to provide treatment for patients at home. A total of 230 patients with chronic low back pain are being identified from a single statewide health system serving US military veterans. Participants are randomized to receive either ten weeks of in-person CBT or IVR-based CBT. The primary outcome is pain intensity as measured by the Numeric Rating Scale immediately post-treatment. Secondary outcomes include pain-related interference, emotional functioning, and quality of life measured immediately post treatment, and 6 and 9 months post recruitment. Exploratory objectives of the study are to examine: (1) potential mediators of impact on clinical outcomes (treatment retention, self-reported skill practice ratings, IVR call adherence, and treatment satisfaction); and (2) moderators of treatment engagement, adherence to therapist recommendations for pain coping skill practice, and effects on clinical outcomes.

Discussion

This non-inferiority trial may identify an alternative to resource intensive in-person CBT that allows many more patients to receive care while also increasing retention of those enrolled in the program.

Trial registration

ClinicalTrials.gov: NCT01025752. Registered 3 December 2009.

Pain Psychology: A Global Needs Assessment and National Call to Action

OBJECTIVE

The Institute of Medicine and the draft National Pain Strategy recently called for better training for health care clinicians. This was the first high-level needs assessment for pain psychology services and resources in the United States.

DESIGN

Prospective, observational, cross-sectional.

METHODS

Brief surveys were administered online to six stakeholder groups (psychologists/therapists, individuals with chronic pain, pain physicians, primary care physicians/physician assistants, nurse practitioners, and the directors of graduate and postgraduate psychology training programs).

RESULTS

1,991 responses were received. Results revealed low confidence and low perceived competency to address physical pain among psychologists/therapists, and high levels of interest and need for pain education. We found broad support for pain psychology across stakeholder groups, and global support for a national initiative to increase pain training and competency in U.S. therapists. Among directors of graduate and postgraduate psychology training programs, we found unanimous interest for a no-cost pain psychology curriculum that could be integrated into existing programs. Primary barriers to pain psychology include lack of a system to identify qualified therapists, paucity of therapists with pain training, limited awareness of the psychological treatment modality, and poor insurance coverage.

CONCLUSIONS

This report calls for transformation within psychology predoctoral and postdoctoral education and training and psychology continuing education to include and emphasize pain and pain management. A system for certification is needed to facilitate quality control and appropriate reimbursement. There is a need for systems to facilitate identification and access to practicing psychologists and therapists skilled in the treatment of pain.

Physical activity, psychiatric distress, and interest in exercise group participation among individuals seeking methadone maintenance treatment with and without chronic pain

BACKGROUND AND OBJECTIVES

Physical activity may improve chronic pain, anxiety, and depression, which are prevalent among patients in methadone maintenance treatment (MMT), but relatively little is known about the physical activity levels or interest in exercise of patients in MMT.

METHODS

We used a brief self-report instrument to assess physical activity levels, chronic pain, psychiatric distress, and interest in exercise group participation among 303 adults seeking MMT.

RESULTS

Most (73%) reported no moderate or vigorous intensity physical activity in the past week; 27% met recommended physical activity levels, and 24% reported interest in exercise group participation. Participants with (compared to those without) chronic pain had higher levels of psychiatric distress and were less likely to meet recommended levels of physical activity (p < .05), but did not differ significantly in their interest in participating in an exercise group. Participants who met recommended levels of physical activity in the past week were more likely to be men and had lower levels of depression than others (p < .05).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Low levels of physical activity and low interest in exercise group participation among patients entering MMT point to the need for and likely challenges of implementing exercise interventions in MMT.