Brief Cognitive Behavioral Therapy for Chronic Pain to Improve Functional Outcomes among Primary Care Veterans

国家指南，如疾病控制中心的指南，建议进行心理治疗 而不是阿片类药物治疗，成为慢性疼痛的首选一线治疗方法。嵌入的行为健康提供者 作为退伍军人事务部国家初级保健-精神卫生一体化(PCMHI)计划的一部分，初级保健-- 通过提供治疗来改善功能恢复，为有疼痛的退伍军人提供支持。认知 行为疗法治疗慢性疼痛被公认为一种安全有效的心理治疗方法。 然而，这种治疗通常是一种漫长的心理治疗(≥10，50分钟疗程)，专为 专门的护理环境。相比之下，PCMHI的服务是简短和有时间限制的(≤6，30分钟会议) 与治疗大量病人的初级保健服务相一致。将治疗范围扩大到 初级保健退伍军人谁提出了疼痛问题，我们开发了一个基于PCMHI的版本，名为 慢性疼痛的简明认知行为疗法(简明CBT-CP)简要的CBT-CP将内容浓缩到 只有六次会议围绕PCMHI提供者使用的30分钟预约结构组织。简要CBT- 最近在一个临床示范项目中对CP进行了评估，该项目发现了一个具有统计学和临床意义的 治疗后疼痛强度和疼痛相关活动的综合测量减少。 平均而言，大多数改善是在治疗的前三个阶段实现的，这表明 简单的CBT-CP有可能产生快速的临床疗效。我们资助的研发尖顶(正在进行中)表明 我们的试验方法的可行性很高，因为我们经常超过计划的每月招聘目标 留存。此外，患者报告了高水平的治疗满意度，PCMHI提供者报告 这一简短的CBT-CP是一种重要而可行的干预措施。根据这些初步研究，这 应用程序建议在[178]退伍军人中进行单盲、双臂、随机对照试验 患有慢性肌肉骨骼疼痛和疼痛相关功能障碍的患者，在 退伍军人事务部西部纽约医疗系统。退伍军人将被随机分为(1)简明CBT-CP和 初级保健照常治疗(TAU)或(2)仅TAU。患者数据将在基线、治疗中期收集 (6周)、治疗后(12周)和随访(6个月)，通过多水平建模进行评估 CBT-CP可迅速减少疼痛相关活动干扰(主要结果)。二级临床 结果(疼痛强度、抑郁症状、自杀意念、生活质量和社会角色投入) 将以同样的方式进行评估。该研究的第二个目标是评估潜在的治疗介体。 (即疼痛自我效能和灾难)和调节因素(即人口统计因素、治疗期望、 阿片类药物和辅助治疗使用)，以确定这些因素是否影响结果。这个 这项研究的第三个目的是通过对患者进行定性访谈，纳入混合方法的组成部分 说明简短的CBT-CP如何有助于改善功能状态和改善生活 订婚。这项研究与RR&D的使命非常一致，并支持全国范围内的VA临床目标 通过在护理轨迹的早期促进对慢性疼痛的安全、可获得的非药物治疗。

National guidelines, such as those from the Centers for Disease Control, recommend psychological therapies over opioid therapy as a preferred first line treatment for chronic pain. Behavioral health providers embedded in primary care as part of the VA’s national Primary Care-Mental Health Integration (PCMHI) program are well- positioned to support Veterans with pain by delivering treatments to improve functional recovery. Cognitive behavioral therapy for chronic pain is widely recognized as a safe and effective psychological treatment. However, this treatment is typically a lengthy psychotherapy (≥10, 50-minute sessions) designed for specialized care settings. In contrast, PCMHI services are brief and time-limited (≤6, 30-minute sessions) to be consistent with primary care services that treat a high volume of patients. To extend the reach of treatment to primary care Veterans who present with a pain concern, we have developed a PCMHI-based version titled Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP). Brief CBT-CP condenses content into only six sessions organized around the 30-minute appointment structure used by PCMHI providers. Brief CBT- CP was recently evaluated in a clinical demonstration project that found a statistically and clinically significant decrease in a composite measure of pain intensity and pain-related activity interreference following treatment. On average, the majority of improvement was achieved in the first three sessions of treatment signaling that Brief CBT-CP can potentially produce rapid clinical benefit. Our funded RR&D SPiRE (in progress) indicates the high feasibility of our trial methods as we frequently exceeded planned monthly recruitment goals with high retention. Additionally, patients have reported high levels of treatment satisfaction and PCMHI providers report that Brief CBT-CP is an important and feasible intervention. Based on these preliminary studies, this application proposes to conduct a single-blind, double-arm, randomized controlled trial among [178] Veterans with chronic musculoskeletal pain and pain-related functional impairment who receive primary care services at the VA Western New York Healthcare System. Veterans will be randomized to either (1) Brief CBT-CP and primary care treatment as usual (TAU) or (2) TAU only. Patient data will be collected at baseline, mid-treatment (6-week), post-treatment (12-week), and follow-up (6-month) to evaluate through multilevel modeling if Brief CBT-CP produces a rapid decrease in pain-related activity interference (primary outcome). Secondary clinical outcomes (pain intensity, depression symptoms, suicidal ideation, quality of life, and social role engagement) will be assessed in the same manner. The second goal of the study is to assess potential treatment mediators (i.e., pain self-efficacy and catastrophizing) and moderators (i.e., demographic factors, treatment expectations, opioid and adjunctive treatment use, therapeutic alliance) to determine if these factors impact outcomes. The third aim of the study incorporates a mixed methods component by including qualitative interviews with patients to illuminate how Brief CBT-CP contributes to improvement in functional status and improved life role engagement. This study is well-aligned with the mission of RR&D and supports the VA clinical goals nationally by promoting a safe, accessible, non-pharmacological treatment for chronic pain early in the trajectory of care.