Center for Care Delivery and Outcomes Research
Taking ACTION to Reduce Pain Full Abstract
Background:
Chronic musculoskeletal pain is one of the most common conditions among Veterans, affecting approximately 60% of those seen in VA primary care. Although perceived effectiveness of chronic pain treatment is low among all VA patients, black patients are less likely than white to perceive their treatment as effective, and are more likely to experience functional limitations due to pain. There is growing consensus that chronic pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental contributors to pain, some of which differ by race and hence contribute to disparities. For example, blacks experience greater pain-related fear and lower self-efficacy in coping with pain (psychological contributors), and neighborhoods that make physical activity difficult (environmental contributors). However, there is a lack of effective interventions to improve pain treatment among minority patients, particularly those that target psychological and environmental contributors.
Objectives:
The primary objective is to test the effectiveness of a multi-component intervention that specifically targets known barriers to effective pain care among black Veterans with chronic musculoskeletal pain. Our primary hypothesis is that a telephone-delivered intervention, which emphasizes walking and incorporates action planning, motivational interviewing (MI) and cognitive behavioral therapy (CBT) techniques, and the use of pedometers, will improve core chronic pain outcomes in black Veterans. Secondarily, we will determine whether our intervention also benefits non-black patients with musculoskeletal pain.
Methods:
We propose a randomized trial to test the effectiveness of the intervention compared with usual care (UC) among 250 black and 250 non-black patients with chronic musculoskeletal pain. Patients from the Atlanta VAMC will be identified using administrative data. Patients will be screened by phone, and, if eligible, will be mailed the full baseline survey. Patients who return a completed baseline will be randomly assigned to the usual care (UC) or intervention condition (IC). Intervention participants will receive a pedometer-mediated walking intervention that will incorporate action planning and the use MI and CBT techniques. The intervention will be delivered in 6 telephone counseling sessions over 8-10 weeks. Participants in the UC condition will receive an informational brochure and a pedometer. The study is powered to find a difference between the IC and UC conditions within the black and non-black groups. The primary outcome is chronic pain-related physical functioning, assessed at 6 months by the revised Roland and Morris Disability Questionnaire (RMDQ), 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 potential mediators targeted by the intervention, exploring whether the intervention affects service utilization and use of opioid analgesics, and exploring whether the intervention reduces racial disparities in pain outcomes. Measures will be assessed by mail and phone survey at baseline, 3 months, and 6 months. Data analysis of primary aims will follow intent-to-treat methodology.
Findings:
None at this time.
Status:
Focus groups were conducted at the Atlanta VAMC in September and October 2015. The Phase 2 pilot was completed during April, May, and June 2016. The pilot involved conducting the intervention counseling with 3 participants (who will not participate in any other phases of the study). Phase 2 fielding began July 2016 and will continue for 18 months.
Impact:
The work proposed is expected to result in a non-pharmacological intervention, delivered by telephone, designed to reduce pain and improve functioning among black patients with musculoskeletal pain, by promoting walking.
