Program to Increase Veterans’ Access to Non-Drug Therapy for Pain Receives Approval for Expansion

May 15, 2023

Takeaway: Based on the success of both HSR&D and QUERI research, VA's Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) will fund a clinical version of COPES - a technology-based cognitive-behavioral therapy program for chronic pain that Veterans can complete from home and on their own schedule. COPES will be available throughout VISN 1 (New England) in early FY2024.

Chronic pain has wide-ranging effects including interference with physical and emotional functioning, sleep, and quality of life. Cognitive behavioral therapy for chronic pain (CBT-CP) is an evidence-based treatment that can reduce pain and associated disability and distress - and has been adopted as a first-line non-pharmacological therapy in the VA healthcare system. However, patient travel, scheduling barriers, and lack of trained clinicians to provide CBT-CP at all facilities limits access to this treatment.

In 2019, more than 20% of adults in the United States suffered with chronic pain (Dahlhamer et al, 2021), and nearly 1 in 10 Veterans return to civilian life with chronic pain (PCORI).

To expand access to CBT-CP, Dr. Alicia Heapy and investigators with HSR&D's Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center developed and evaluated the "Cooperative Pain Education and Self-management" or COPES program. COPES is a technology-based 11-week, self-directed CBT program for chronic pain that Veterans can complete from home, using their telephone. Veterans learn pain management skills using a handbook, engage in a walking program, and set goals for meaningful activities. Veterans complete a daily, automated two-minute call answering questions about their pain, sleep, steps, and skill use-and then receive a weekly personalized voice message from a master's level coach based on the information provided during the calls. An HSR&D funded non-inferiority trial showed that patients in COPES did just as well as those receiving in-person CBT-CP and reported improvements in physical functioning, sleep, steps, and pain.

Based on these findings, investigators began a new study designed to build on the program's strengths and to address the barriers to program implementation. Led by Drs. Alicia Heapy and John Piette, researchers with HSR&D's Improving Pain-Related Outcomes for Veterans (IMPROVE) QUERI, including Drs. Will Becker and Amanda Midboe, evaluated the effectiveness of a direct-to-patient outreach strategy to increase uptake of COPES relative to standard provider referral among Veterans with chronic musculoskeletal pain who received care at five community-based outpatient clinics (CBOCs) affiliated with the VA Boston Healthcare System.

Findings

Offering COPES directly to patients engaged significantly more Veterans than clinician referral (by a margin of 9:1). Direct outreach allowed interested patients to quickly access evidence-based treatment. In addition to clinician referral, Veterans will be able to self-refer to the program. Self-referral allows interested Veterans to quickly access treatment from home while reducing wait times for patients who prefer or require in person CBT-CP.

The COPES program and its implementation was further adapted and is currently being evaluated in nine VA sites in an ongoing pragmatic effectiveness trial, funded by the NIH-DoD-VA Pain Management Collaboratory. Using data from the past and present COPES trials, it is estimated that a team of five master's level pain coaches working from a single remote location, each providing 20% effort, can treat 250 Veterans per year at a cost that is comparable to that of one full-time pain psychologist. The centrally located team model allows COPES to be delivered to a wide geographic area that can aid lower resourced and rural facilities, in particular. These findings informed care and policy decisions in VA related to a wider rollout of the COPES program.

Impact

Based on the success of both HSR&D and QUERI research, VA's Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) has funded a clinical version of COPES that will be available throughout VISN 1 in FY2024.

Partners

Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP), and VA Primary Care Services (PCS).

Publications

Becker W, DeBar L, Heapy A, et al. A research agenda for advancing non-pharmacological management of chronic musculoskeletal pain: Findings from a VHA state-of-the-art conference. Journal of General Internal Medicine. May 2018;33(Suppl 1):11-15.

Heapy A, Driscoll M, Buta E, et al. COPES Expanding Treatment for Real-world Access (ExTRA): Pragmatic Trial Protocol. Pain Medicine. December 2020;21(12 Suppl 2):S21-S28.

Heapy A, Higgins D, Driscoll M, et al. Cooperative pain education and self-management (COPES): A non-inferiority trial of an interactive voice response-based self-management intervention for chronic back pain: The COPES Non-inferiority Randomized Trial. JAMA Internal Medicine. June 2017;177(6):765-773.

Heapy A, Tankha M, Higgins D, et al. Incorporating walking into cognitive behavioral therapy for chronic pain: Safety and effectiveness of a personalized walking intervention. Journal of Behavioral Medicine. April 2021;44(2):260-269.

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