"It Made Me Not Want to See him ": The Role of Patient-Provider Communication in Influencing Rural-Dwelling Women Veterans' Motivation to Seek Health Care for Managing Chronic Pain.

Despite being high health care utilizers, many women Veterans perceive their pain condition to be poorly understood by their providers, which can be a strong demotivator for seeking care. We set out to understand the priorities rural-dwelling women Veterans have for using health care for their chronic pain, and interviewed participants about their experiences with (and priorities for seeking) health care for their chronic pain. Self-Determination Theory identifies three sources of motivation (autonomy, competence, relatedness), all of which were represented through two themes that reflect rural women Veterans' rationale for decision-making to obtain health care for chronic pain: role of trust and competing priorities. Women described their priorities for chronic pain management in terms of their competing priorities for work, education, and supporting their family, but most expressed a desire to function in their daily life and relationships. Second, women discussed the role of trust in their provider as a source of motivation, and the role of patient-provider communication skills and gender played in establishing trust. Rural women Veterans often discussed core values that stemmed from facets of their identity (e.g. gender, military training, ethnicity) that also influenced their decision-making. Our findings provide insight for how providers may use Motivational Interviewing and discuss chronic pain treatment options so that rural-dwelling women Veterans feel autonomous, competent, and understood in their decision-making about their chronic pain. We also discuss importance of acknowledging the effects of disenfranchising talk and perpetuating gendered stereotypes related to chronic pain and theoretical implications of this work.

Military Veterans' Perspectives on Postoperative Opioid Use: A Secondary Analysis of Qualitative Data.

PURPOSE: This qualitative analysis of interviews with surgical patients who received a brief perioperative psychological intervention, in conjunction with standard medical perioperative care, elucidates patient perspectives on the use of pain self-management skills in relation to postoperative analgesics. DESIGN: This study is a secondary analysis of qualitative data from a randomized controlled trial. METHODS: Participants (N = 21) were rural-dwelling United States Military Veterans from a mixed surgical sample who were randomized to receive a manual-based, telephone-based Perioperative Pain Self-management intervention consisting of a total of four pre- and postoperative contacts. Semi-structured qualitative interviews elicited participant feedback on the cognitive-behavioral intervention. Data was analyzed by two qualitative experts using MAXQDA software. Key word analyses focused on mention of analgesics in interviews. FINDINGS: Interviews revealed a dominant theme of ambivalence towards postoperative use of opioids. An additional theme concerned the varied ways acquiring pain self-management skills impacted postoperative opioid (and non-opioid analgesic) consumption. Participants reported that employment of pain self-management strategies reduced reliance on pharmacology for pain relief, prolonged the time between doses, took the "edge off" pain, and increased pain management self-efficacy. CONCLUSIONS: Perioperative patient education may benefit from inclusion of teaching non-pharmacologic pain self-management skills and collaborative planning with patients regarding how to use these skills in conjunction with opioid and non-opioid analgesics. Perianesthesia nurses may be in a critical position to provide interdisciplinary postoperative patient education that may optimize postoperative pain management while minimizing risks associated with prolonged opioid use.

The Perioperative Pain Self-Management (PePS) randomized controlled trial protocol: Preventing chronic post-surgical pain and prolonged opioid use.

BACKGROUND: Total joint arthroplasties are common orthopedic surgeries that carry risk for developing chronic post-surgical pain. In addition to pre- and post-operative pain severity, psychological distress (e.g., anxiety, pain catastrophizing) is a risk factor for chronic postsurgical pain. Cognitive behavioral therapy (CBT) for chronic pain is an empirically supported approach to managing chronic pain, functional impairment, and related distress. While CBT has been used extensively in patients with established chronic pain, using it as a preventive intervention targeting the transition from acute to chronic postsurgical pain is a novel application. OBJECTIVES: The Perioperative Pain Self-Management (PePS) program is a pain self-management intervention based on the principles of CBT. This innovative intervention is brief, flexible, and is delivered remotely. The current study aims to determine the efficacy of PePS compared to standard care on reducing the incidence of significant surgical site pain at 6-months post-surgery. The current study also aims to evaluate the context for subsequent implementation. METHODS: This study is a hybrid type I efficacy-preparing for implementation trial. It is a two-site, single-blind, two-arm, parallel, randomized control trial. Surgical patients will be randomized to either receive: 1) PePS plus standard care, or 2) Standard care. The primary end point will be surgical site pain severity at 6-months post-surgery. CONCLUSION: Results from this study are expected to result in support for a brief scalable intervention (PePS) that can prevent the development of chronic pain and prolonged post-surgical opioid use, as well as key details to inform subsequent implementation. CLINICALTRIALS: govIdentifier:NCT04979429.

The Impact of Preoperative Distress: A Qualitative analysis of the Perioperative Pain Self-Management Intervention.

PURPOSE: Preoperatively distressed patients are at elevated risk for chronic postsurgical pain. Active psychological interventions show promise for mitigating chronic postsurgical pain. This study describes experiences of preoperatively distressed (elevated depressive symptom, anxious symptoms, or pain catastrophizing) and non-distressed participants who participated in the psychologically based Perioperative Pain Self-management (PePS) intervention. DESIGN: This is a qualitative study designed to capture participants' perspectives and feedback about their experiences during the PePS intervention. METHODS: Interviews were semi-structured, conducted by telephone, audio-recorded, transcribed, and audited for accuracy. Coded interviews were analyzed using a quote matrix to discern possible qualitative differences in what preoperatively distressed and non-distressed participants found most and least helpful about the intervention. RESULTS: Twenty-one participants completed interviews, 7 of whom were classified as distressed. Distressed participants identified learning how to reframe their pain as the most helpful part of the intervention. Non-distressed participants focused on the benefit of relaxation skill-building to manage post-surgical pain. Distressed and non-distressed participants both emphasized the importance of the social support aspects of PePS and- identified goal-setting as challenging. CONCLUSIONS: Distressed and non-distressed participants emphasized different preferences for pain management strategies offered by PePS. Most participants emphasized the importance of social support that PePS provided. CLINICAL IMPLICATIONS: Our results indicate that post-operative patients may benefit from interpersonal interaction with a trained interventionist. Our findings also suggest that distressed and non-distressed patients may benefit from varied intervention approaches. How to build flexibility into a manualized intervention or whether these subsets of patients would benefit more from different interventions is a direction for future research.

Enhancing the Biopsychosocial Approach to Perioperative Care: A Pilot Randomized Trial of the Perioperative Pain Self-management (PePS) Intervention.

OBJECTIVE: The current study aimed to pilot the PePS intervention, based on principles of cognitive behavioral therapy (CBT), to determine feasibility and preliminary efficacy for preventing chronic pain and long-term opioid use. SUMMARY BACKGROUND DATA: Surgery can precipitate the development of both chronic pain and long-term opioid use. CBT can reduce distress and improve functioning among patients with chronic pain. Adapting CBT to target acute pain management in the postoperative period may impact longer-term postoperative outcomes. METHODS: This was a mixed-methods randomized controlled trial in a mixed surgical sample with assignment to standard care or PePS, with primary outcomes at 3-months postsurgery. The sample consisted of rural-dwelling United States Military Veterans. RESULTS: Logistic regression analyses found a significant effect of PePS on odds of moderate-severe pain (on average over the last week) at 3-months postsurgery, controlling for preoperative moderate-severe pain: Adjusted odds ratio = 0.25 (95% CI: 0.07-0.95, P < 0.05). At 3-months postsurgery, 15% (6/39) of standard care participants and 2% (1/45) of PePS participants used opioids in the prior seven days: Adjusted Odds ratio = 0.10 (95% CI: 0.01-1.29, P = .08). Changes in depression, anxiety, and pain catastrophizing were not significantly different between arms. CONCLUSIONS: The findings from this study support the feasibility and preliminary efficacy of the PePS intervention.