Three Yale and VA Connecticut Healthcare System research teams have been awarded federal grants as part of a multi-year study of how to manage chronic pain in veterans and active military members without the use of drugs.
The Yale and VA research projects are included in a total $81 million package funded by three federal agencies and the National Center for Complementary and Integrative Health (NCCIH) to develop, implement, and test methods of treating pain and related conditions without medication.
Helping veterans and service members manage pain is a priority for the military and agencies like the U.S. Department of Health and Human Services, U.S. Department of Defense (DOD) and U.S. Department of Veterans Affairs (VA), which are helping to fund the research.
An estimated 45 percent of service members and 50 percent of veterans regularly experience pain. While opioids are often prescribed for treatment, their efficacy can be limited, and they pose a risk of abuse and addiction, said Dr. George Ludwig, principal assistant for research and technology, U.S. Army Medical Research and Material Command.
"The proposals funded under this interagency partnership will provide a significant step forward in pain management in our wounded service members," Ludwig said.
Grant to fund creation of Pain Management Collaboratory Coordinating Center
At Yale, three faculty will work during the next six years to develop the Pain Management Collaboratory Coordinating Center (PMC3). The PMC3 will provide national leadership and serve as a national resource in the conducting of high impact pragmatic clinical trials on nondrug approaches to manage pain and other comorbid conditions in veteran and military health care systems.
The research will be led by an interdisciplinary team of three principal investigators at Yale: Robert D. Kerns, PhD; Cynthia A. Brandt, MD, MPH; and Peter N. Peduzzi, PhD. Kerns is Professor of Psychiatry, Neurology and Psychology at Yale and maintains an appointment as Research Psychologist at the Pain Research, Informatics, Multimorbidities and Education (PRIME) Center. He is a recognized expert in pain management and clinical and health services research targeting veterans.
Brandt is Professor of Emergency Medicine, Director of Yale Center for Medical Informatics (YCMI), and Director of Informatics for the Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center at VA Connecticut Healthcare System. She brings expertise in electronic health records (EHR) and data systems.
Peduzzi is Professor of Biostatistics at the Yale School of Public Health and Director of the Yale Center for Analytical Sciences. He brings expertise in the design and coordination of multi-site pragmatic trials.
They will be assisted by faculty and staff from other universities and the VA and DOD. The PMC3 will establish work groups to work collaboratively with and to provide technical, design, and other support to the funded demonstration project teams to develop and implement non-pharmacologic pain management pragmatic trials.
Researcher to study technology-assisted cognitive behavioral therapy
A second grant, awarded to Alicia A. Heapy, PhD, Associate Professor of Psychiatry at Yale and Associate Director of the Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center at VA Connecticut Healthcare System, will fund a study to evaluate the effectiveness of a technology-based form of cognitive behavioral therapy for chronic pain (CBT-CP) in the VA system.
CBT-CP is an evidence-based psychological intervention that is effective in reducing pain and improving function for patients with chronic pain. However, numerous barriers exist to face-to-face delivery of this treatment, including patient travel limitations, the need for frequent in-person sessions, and the scarcity of trained therapists.
Technology-based interventions, like interactive voice response (IVR), which allows patients to engage in treatment from their home, may improve access to CBT-CP, Heapy said.
The goal of the six-year project is to conduct a pragmatic trial to examine the real-world effectiveness of an IVR-based form of CBT-CP called COoperative Pain Education and Self-management (COPES) versus in-person CBT-CP.
Heapy said she wants to address the widely-recognized gap between evidence of effectiveness of nondrug approaches for chronic pain management, including CBT, and equitable and timely access to these approaches. Her interest in comparing the real-world outcomes of COPES and CBT-CP is rooted in real world choices that health systems and clinicians confront.
"Is there clear evidence of superiority of COPES versus in-person treatment and thus, cause to recommend one treatment over the other?" she said. "Alternatively, if there is not, and CBT-CP and COPES can be regarded as alternative forms of the same treatment, then providers can confidently rely on patient preference and local availability to determine what is offered to patients."
Additionally, identification of patient characteristics - like age, gender, pain features and co-occurring conditions - that predict or moderate a positive response to CBT-CP (in either form) or induce preferential response to one treatment relative to another can meaningfully guide policy and clinical decisions, Heapy said.
Investigators to study an intervention to reduce pain and risky substance use
The third grant to Yale investigators was awarded to Marc Rosen, MD, Professor of Psychiatry and staff psychiatrist at the VA Connecticut Healthcare System, and Steve Martino, PhD, Professor of Psychiatry and Chief of Psychology at the VA Connecticut Healthcare System.
Rosen and Martino will test the effectiveness and cost-effectiveness of Screening, Brief Intervention, and Referral to Treatment for Pain Management (SBIRT-PM) in reducing pain and risky substance use among veterans seeking compensation for musculoskeletal conditions.
Their study will occur at all eight VA medical centers in New England and be rolled out in two phases.
During the first two years, the research team will arrange for clinicians at VA Connecticut (the hub) to counsel veterans at the other New England medical centers (the spokes) by phone with SBIRT-PM and coordinate referral to nondrug pain treatment and addiction services. This phase will include piloting SBIRT-PM; qualitative interviews with veterans, clinicians, and administrators; and the development and testing of natural language processing computerized algorithms to scan electronic medical records for veterans’ use of nondrug pain treatments.
The study will then proceed to a four-year period to conduct a pragmatic clinical trial about SBIRT-PM’s effectiveness and to disseminate its findings.
Rosen and Martino believe that screening, brief intervention, and referral to treatment at compensation examinations can transform a widely-used point of entry to VA into a health-promoting encounter.
If SBIRT-PM is effective and cost-effective, a similar hub-and-spoke model of implementation could be used to disseminate its use for veterans in other regions of the country, they said.
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