Telehealth and Rural-Urban Differences in Receipt of Pain Care in the Veterans Health Administration.

OBJECTIVE: Examine changes in specialty pain utilization in the Veterans Health Administration (VHA) after establishing a virtual interdisciplinary pain team (TelePain). DESIGN: Retrospective cohort study. SETTING: A single VHA healthcare system, 2015-2019. SUBJECTS: 33,169 patients with chronic pain-related diagnoses. METHODS: We measured specialty pain utilization (in-person and telehealth) among patients with moderate to severe chronic pain. We used generalized estimating equations to test the association of time (pre- or post-TelePain) and rurality on receipt of specialty pain care. RESULTS: Among patients with moderate to severe chronic pain, the reach of specialty pain care increased from 11.1% to 16.2% in the pre- to post-TelePain periods (adjusted odds ratio [aOR]: 1.37, 95% confidence interval [CI]: 1.26-1.49). This was true of both urban patients (aOR: 1.62, 95% CI: 1.53-1.71) and rural patients (aOR: 1.16, 95% CI: 0.99-1.36), although the difference for rural patients was not statistically significant. Among rural patients who received specialty pain care, a high percentage of the visits were delivered by telehealth (nearly 12% in the post-TelePain period), much higher than among urban patients (3%). CONCLUSIONS: We observed increased use of specialty pain services among all patients with chronic pain. Although rural patients did not achieve the same degree of access and utilization overall as urban patients, their use of pain telehealth increased substantially and may have substituted for in-person visits. Targeted implementation efforts may be needed to further increase the reach of services to patients living in areas with limited specialty pain care options.

Bringing chronic-pain care to rural veterans: A telehealth pilot program description.

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive-behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A randomized controlled trial to influence client language in substance use disorder treatment.

BACKGROUND: Client language is hypothesized to be a mechanism of action in motivational interviewing (MI). Despite the association of change and sustain talk with substance treatment outcomes, it not known whether providers can intentionally influence this language as hypothesized. OBJECTIVE: This is a randomized controlled trial to investigate whether substance use providers can be trained to influence client language. METHODS: Treatment providers specializing in substance use disorders (n=190) were randomly assigned to standard training in MI (MI-AU) or training emphasizing an influence of client language (MI-LEAF). Treatment sessions with actual clients were evaluated 3, 6 and 12 months after training by masked raters. Frequencies of client change and sustain talk were the outcome variables. RESULTS: Sustain talk, but not change talk, was significantly lower in clients whose providers had received the specialized training (b=-0.175, SE=0.087, p=0.046, CI[-0.348 to 0.002], d=-0.325). Mediation analyses supported a causal chain between a) training, b) providers' attempts to minimize sustain talk in treatment sessions via directive reflective listening and c) client sustain talk in the treatment session (κ2=0.0833, bootstrap SE=0.0394, 95% CI [0.0148, 0.1691]). CONCLUSIONS: With specialized training, providers can reduce the amount of opposition language their clients offer when considering a change in their substance use. Demonstrating that client language is under partial control of the provider supports the feasibility of clinical trials to investigate the impact of shaping client language on treatment outcomes.

Methadone "callbacks" within a veterans affairs opioid treatment program: Detecting methadone misuse.

BACKGROUND AND OBJECTIVES: A "callback" requires patients to bring in take-home methadone doses for inspection. An opioid treatment program (OTP) quality-improvement project examined random versus "for-cause" callbacks. METHOD: Eighty-two random callbacks and 60 for-cause callbacks were conducted among patients enrolled in an OTP (N = 183). RESULTS: Among patients with more take home doses, 6% of random callbacks versus 44% of for-cause callbacks were failed. Among patients with fewer take home doses, 36% of for-cause callbacks were failed. DISCUSSION AND CONCLUSIONS: For-cause callbacks are more useful than random ones. SCIENTIFIC SIGNIFICANCE: For-cause callbacks based on clinical judgment detect methadone misuse. (Am J Addict 2017;26:50-52).

CACTI: free, open-source software for the sequential coding of behavioral interactions.

The sequential analysis of client and clinician speech in psychotherapy sessions can help to identify and characterize potential mechanisms of treatment and behavior change. Previous studies required coding systems that were time-consuming, expensive, and error-prone. Existing software can be expensive and inflexible, and furthermore, no single package allows for pre-parsing, sequential coding, and assignment of global ratings. We developed a free, open-source, and adaptable program to meet these needs: The CASAA Application for Coding Treatment Interactions (CACTI). Without transcripts, CACTI facilitates the real-time sequential coding of behavioral interactions using WAV-format audio files. Most elements of the interface are user-modifiable through a simple XML file, and can be further adapted using Java through the terms of the GNU Public License. Coding with this software yields interrater reliabilities comparable to previous methods, but at greatly reduced time and expense. CACTI is a flexible research tool that can simplify psychotherapy process research, and has the potential to contribute to the improvement of treatment content and delivery.

Chasing change talk: the clinician's role in evoking client language about change.

Client "change talk," or language in favor of changing a target behavior, is a hypothesized active ingredient of motivational interviewing that can predict actual behavioral change. This study isolated and manipulated change talk in a context resembling a psychotherapeutic encounter, comparing its prevalence in two conditions: change talk evocation (CT) and functional analysis (FA). Using a single-baseline (ABAB) design, clinicians alternated between CT and FA, consequating change talk only in the CT condition. Clinicians were 9 clinical psychology graduate students, and clients were 47 undergraduates with concerns about drinking. The hypothesis that greater Percentage Change Talk would be observed in CT than in FA was supported, t(46) = 6.561, p < .001, d = 1.19. A rationale for the development of a behavioral rating system to evaluate clinicians' proficiency in recognizing, responding to, and evoking client change talk is presented.

Brief Interventions for Tobacco Users: Using the Internet to Train Healthcare Providers.

One fifth of Americans smoke; many have no plans to quit. Motivational Interviewing (MI) is an effective approach to intervention with precontemplative smokers, yet a substantial number of healthcare practitioners lack training in this approach. Two interactive online tutorials were developed to teach practitioners to deliver brief tobacco cessation interventions grounded in the MI approach. The tutorials emphasized the unique aspects of working with precontemplative smokers, incorporating audio and video examples of best practices, interactive exercises, targeted feedback, and practice opportunities. One hundred and fifty-two healthcare providers-in-training were randomly assigned to use the online tutorials or to read training material that was matched for content. A virtual standardized patient evaluation was given before and after the training. Both groups improved their scores from pre- to posttest; however, the tutorial group scored significantly better than the reading group at posttest. The results of this study demonstrate the promise of interactive online tutorials as an efficient and effective way to deliver clinical education.