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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 Veterans with chronic pain.
Chronic pain has wide-ranging effects including interference with physical and emotional functioning, sleep, and quality of life. Cognitive behavioral therapy (CBT) focuses on the relationship among thoughts, emotions, and behaviors; it can be delivered alone or as part of an integrated pain management program. CBT 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.
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 for chronic pain, 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 uses interactive voice response (IVR) technology to allow Veterans to participate in treatment from their homes, using their telephone. Veterans learn pain management skills, engage in a walking program, and set goals for meaningful activities. Veterans receive a handbook, a pedometer, and a daily automated, two-minute call that asks about their pain, sleep, steps, skill use, and goals-in addition to a weekly personalized voice message from a COPES coach about patterns and trends identified from the daily data, goals to work towards, and guidance for the following week. Investigators evaluated the effectiveness of COPES relative to standard in-person CBT-CP in an HSR&D funded non-inferiority trial that showed that patients in COPES did just as well as those receiving in-person treatment 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 (PIs: Will Becker, Amanda Midboe and Alicia Heapy) 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 VA Boston Healthcare
Qualitative interviews of Veterans who participated helped the investigators understand what was important to Veterans regarding this treatment, how to improve communication to providers, and how to best reach the patients who may benefit from CBT-CP.
Findings
Investigators found that offering COPES directly to patients engaged significantly more Veterans than traditional referral pathways (by a margin of 10:1). Direct outreach may allow interested patients to quickly access evidence-based treatment earlier in the course of their pain. 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. [For more information about the NIH-DoD-VA Pain Management Collaboratory, visit https://painmanagementcollaboratory.org/.] 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. COPES provides a means for remote patient participation that can aid lower resourced facilities. These findings helped inform 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) will fund a clinical version of COPES, a technology-based, accessible, sustainable version cognitive-behavioral therapy for chronic pain.
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.