The acceptability and feasibility of screening, brief intervention, and referral to treatment for pain management among new England veterans with chronic pain: A pilot study.

OBJECTIVES: Musculoskeletal disorders often lead to chronic pain in Veterans. Chronic pain puts sufferers at risk for substance misuse, and early intervention is needed for both conditions. This pilot study tested the feasibility and acceptability of a Screening, Brief Intervention, and Referral to Treatment for Pain Management intervention (SBIRT-PM) to help engage Veterans seeking disability compensation for painful musculoskeletal disorders in multimodal pain treatment and to reduce risky substance use, when indicated. METHODS: This pilot study enrolled 40 Veterans from 8 medical centers across New England in up to 4 sessions of telephone-based counseling using a motivational interviewing framework. Counseling provided education about, and facilitated engagement in, multimodal pain treatments. Study eligibility required Veterans be engaged in no more than 2 Veteran Affairs (VA) pain treatment modalities, and study participation involved a 12-week postassessment and semistructured interview about the counseling process. RESULTS: Majorities of enrolled Veterans screened positive for comorbid depression and problematic substance use. Regarding the offered counseling, 80% of participants engaged in at least one session, with a mean of 3 sessions completed. Ninety percent of participants completed the postassessment. Numerically, most measures improved slightly from baseline to week 12. In semistructured interviews, participants described satisfaction with learning about new pain care services, obtaining assistance connecting to services, and receiving support from their counselors. DISCUSSION: It was feasible to deliver SBIRT-PM to Veterans across New England to promote engagement in multimodal pain treatment and to track study outcomes over 12 weeks. Preliminary results suggest SBIRT-PM was well-received and has promise for the targeted outcomes.

Evaluation of an Integrated, Multidisciplinary Program to Address Unsafe Use of Opioids Prescribed for Pain.

Objectives: Unsafe use of opioids prescribed for pain is a common challenge in primary care. We aimed to describe a novel clinical program designed to address this issue-the Opioid Reassessment Clinic-and evaluate preliminary efficacy. Methods: The Opioid Reassessment Clinic is a multidisciplinary care team staffed by an internist, addiction psychiatrist, advanced practice nurse, and health psychologist designed to perform enhanced assessment and longitudinal treatment of patients with unsafe use of opioids prescribed for pain. We assessed preliminary efficacy of the clinic using a priori-defined metrics at the patient, provider, clinic process, and health system levels. Results: Of referred patients (N = 87), 84% had a history of substance abuse/dependence and 70% had current misuse of prescribed opioids; 22% received a new substance use disorder diagnosis, each of whom engaged in addiction treatment. Among primary care physicians, 48% referred a patient to the clinic. In terms of process metrics, high fidelity to structured clinical assessments was assisted by templated electronic progress notes. Wait time averaged 22.1 days while length of treatment averaged 137 days. Urine drug testing was performed on 91% of patients an average of 6.4 times, while assessing out-of-system opioid receipt occurred universally. Systems-level findings included evidence of institutional support: hiring a nurse case manager to help with care coordination. Conclusions: Results suggest the Opioid Reassessment Clinic was effective in the management of a small group of high-complexity patients. Wide-scale dissemination may require adapted care models.

Multimodal Treatment Options, Including Rotating to Buprenorphine, Within a Multidisciplinary Pain Clinic for Patients on Risky Opioid Regimens: A Quality Improvement Study.

Objectives: We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain-the Opioid Reassessment Clinic (ORC)-to inform practice and health system improvement. Design: Controlled, retrospective cohort study. Setting: The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Subjects: We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group). Methods: We compared a priori-defined metrics at the patient, clinic process, and health system levels and compared metrics between groups. Results: During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0-120] vs 0 mg [IQR = 0-20] decrease, P < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP. Conclusions: Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed.

Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management.

Objective: The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. Design: An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Subjects: Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). Methods: We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. Results: We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Conclusions: Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.

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.

A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management.

BACKGROUND: Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined. OBJECTIVE: Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period. DESIGN: As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period. SUBJECTS: We studied Veterans receiving long-term (90+ consecutive days) OT through primary care. INTERVENTIONS: We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives. MAIN MEASURES: We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics. KEY RESULTS: The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased. CONCLUSIONS: We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project's design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

The moderating effect of obesity on cognitive-behavioral pain treatment outcomes.

OBJECTIVE: To assess the effects of body mass index on cognitive-behavioral pain treatment outcomes for chronic low back pain. DESIGN: Retrospective analyses of data from a clinical trial were performed, with body mass index used to divide patients into obese and non-obese groups for comparison. SETTING: VA medical center outpatient clinic. PATIENTS: Veterans (N = 74) receiving outpatient care through the VA. INTERVENTIONS: Delivery of a 10-week cognitive-behavioral pain treatment intervention. OUTCOME MEASURES: The Numerical Rating Scale (pain intensity), Roland Morris Disability Questionnaire (disability), Veteran's SF-36 (health-related quality of life), and Beck Depression Inventory (emotional functioning) were administered pre- and post-treatment. RESULTS: The study included 42 obese and 32 non-obese participants, most of whom were male (89%). The average body mass index was 32.44 kg/m², with average pain intensity rated as 6.59 out of 10. There were no pre-treatment differences in outcome measures between the groups. Repeated measures ANOVAs revealed main effects of Time on all but one outcome (Mental Component score), indicating that the cognitive-behavioral interventions were largely effective. However, Time-body mass index (BMI) group interactions revealed that non-obese participants showed greater improvement following treatment than did their obese counterparts on measures of disability (P < 0.05), physical aspects of quality of life (P < 0.01), and emotional functioning (P < 0.05). CONCLUSIONS: Standard cognitive-behavioral pain treatment did not yield comparable outcomes for obese and non-obese participants. Results suggest a potential moderating role of BMI in low back pain outcomes. Future work with other pain conditions, including examination of potential mechanisms through which BMI impacts treatment outcomes, is recommended.

Effect of Diaphragmatic Breathing on Procedural Anxiety During Transrectal Prostate Biopsy.

OBJECTIVE: To improve the tolerability of transrectal ultrasound guided prostate biopsy through use of diaphragmatic breathing. METHODS: Forty-seven patients, aged 52-79 years, who were scheduled for a transrectal ultrasound guided prostate biopsy with or without MRI guidance, were recruited at a single Veterans Affairs medical center for the diagnosis or evaluation of prostate cancer. Patients either met with a health psychologist for a 1-time, diaphragmatic breathing intervention immediately prior to their biopsy, or received usual care. All biopsies were performed using local anesthetic without sedation or anxiolytic therapy. The primary outcome was the difference in self-reported procedural situational anxiety as measured with the State Trait Anxiety Inventory, assessed both pre- and post-transrectal ultrasound guided prostate biopsy. We also examined secondary outcomes including physiological parameters (heart rate and blood pressure). RESULTS: There were no significant differences in preprocedural anxiety or physiological parameters between patients who received the intervention and those who received usual care. Patients who received the intervention had a significantly larger decrease in situational anxiety from pre- to postprocedure (M = 14.15, SD = 6.64) compared with those who received usual care (M = 3.45, SD = 9.97); t (38) = -4.0, P <.000; d = 1.26. Patients who received the intervention had a significantly larger decrease in heart rate (bpm) from pre- to postprocedure (M = 10.63, SD = 12.21) compared with those who received usual care (M = 0.07, SD = 9.25); t (31) = 2.75 P = 0.010; d = 0.97. CONCLUSION: A guided diaphragmatic breathing intervention reduced procedural anxiety during prostate biopsy and improved patient experience.

Associative and phonological priming effects after letter search on the prime.

Responses to target words typically are faster and more accurate after associatively related primes (e.g., "orange-juice") than after unrelated primes (e.g., "glue-juice"). This priming effect has been used as an index of semantic activation, and its elimination often is cited as evidence against semantic access. When participants are asked to perform a letter search on the prime, associative priming typically is eliminated, but repetition and morphological priming remain. It is possible that priming survives letter search when it arises from activity in codes that are represented before semantics. This experiment examined associative and phonological priming to determine whether priming from phonologically related rhymes would remain after letter search (e.g., "moose-juice"; rhyming items were orthographically dissimilar). When participants read the primes, equivalent associative and phonological priming effects were obtained; both effects were eliminated after letter search. The impact of letter search on semantic and phonological access and implications for the structural arrangement of lexical and semantic memory are discussed.

Tailoring cognitive-behavioral therapy for chronic pain: a case example.

Cognitive-behavioral therapy (CBT) has been shown to be an effective treatment for chronic pain. However, many patients who might benefit from this treatment either refuse treatment, fail to adhere to treatment recommendations, or drop out prematurely. Adherence to and engagement in CBT for chronic pain might be improved by tailoring a limited number of its components to individual preferences. Motivational interviewing, in which the therapist facilitates the patient's motivation for changing behavior, might also promote CBT engagement and adherence. We describe components of a tailored CBT treatment for chronic pain in the context of ongoing research and illustrate the process of tailoring CBT with a case study.