NATIONAL HARBOR, Md. — A brief cognitive behavioral therapy (CBT) program showed promise in treating chronic pain among Veteran Affairs (VA) patients, a clinical demonstration project showed.
By mid-treatment, chronic pain patients showed significant improvements in pain interference and pain self-efficacy, reported Gregory Beehler, PhD, MA, of the VA Center for Integrated Health Care in Buffalo, New York, and colleagues, at the American Academy of Pain Medicine annual meeting.
The program also was well received by primary care behavioral health providers. “They were very receptive to it,” Beehler said. “They found the materials easy to use and said they’d be happy to use it following our project.”
CBT can be effective in managing pain, but often involves lengthy treatment delivered in specialized clinics, Beehler noted. “Our goal was to see whether we could get a brief version of cognitive behavioral therapy for chronic pain up and running and working in primary care,” he said in a interview with MedPage Today.
Brief psychological pain treatment is the future, observed Beth Darnall, PhD, of Stanford University in California, who was not part of the VA project.
“Expanding access to behavioral treatment means meeting patients where they are and in a way that works for them,” Darnall told MedPage Today. “We need to package behavioral medicine treatments for pain in ways that are practical and feasible for patients to attend and engage in.”
Medical evaluation and care are important, but other approaches are needed to address the full definition of pain, she added. “Individuals can become equipped with information, skills, and strategies that help them better manage the negative impacts of pain,” she continued. “This can help them reduce aspects of suffering, alter the trajectory of pain, and for some patients, can even help reduce the need for medical care.”
The VA project involved 118 chronic pain patients and 23 primary care behavioral health providers. Primary care behavioral health providers — clinical psychologists, social workers, and mental health counselors — are mandated in VA primary care clinics; they address a wide range of emotional and behavioral concerns but most are not chronic pain experts, Beehler explained.
The average patient age was 51 and 75% were men. Providers had limited experience treating chronic pain; they received a manual and webinar about the program and had access to an expert by email and phone as needed.
The program involved six 30-minute, one-on-one sessions aimed at reducing functional limitations of patients with chronic musculoskeletal pain. The modules addressed the following topics:
- Education and identifying goals
- Activities, pacing and fear of movement
- Relaxation training, including deep breathing and muscle relaxation
- Recognizing unhelpful thoughts
- Modifying unhelpful thoughts
- Creating an action plan for future success
After the third session, a composite measure of pain intensity and functional limitations identified statistically significant improvements (d=0.65) in patients. Pain-related self-efficacy outcomes demonstrated a similar pattern (d=0.22). An exploratory analysis showed that the most significant gains in treatment outcomes were associated with the modules involving education and goal setting, pacing, and relaxation training.
In a follow-up survey of 14 providers, 79% said they were either satisfied or very satisfied with the brief CBT program and 86% would continue to use it in the future. Nearly all (93%) respondents said they felt confident using the brief CBT program after training.
“The providers also helped us identify areas for future work,” including barriers to local implementation and areas for additional training, Beehler noted. About half of providers wanted to know more about pain pathophysiology; some asked for education about other non-drug pain treatments or the role of analgesics.
The VA’s next steps include more research into the effectiveness of the brief CBT program, Beehler said. A key lesson learned so far, he noted, is that “providers working in everyday settings can make this happen relatively quickly.”
This project was supported by the VA Center for Integrated Health Care and the VA Western New York Healthcare System.