Tailored Non-Pharmacotherapy Services for Chronic Pain: Testing Scalable and Pragmatic Approaches

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SUMMARY High impact chronic pain is persistent and limits life and work activities for one in ten adults. Evidence- based cognitive-behavioral therapy for chronic pain (CBT-CP) is widely accepted, effective, and does not rely on drugs such as opioids. Most professionals trained in CBT-CP are in urban areas, creating a need for these services in medically underserved and rural areas. Our three-arm comparative effectiveness trial will rigorously evaluate two low-cost, scalable ways to deliver CBT-CP: online via the established PainTRAINER program and by phone using PainTRAINER components. Comparison will be to usual care with a pain-management guide from the American Chronic Pain Association. Our long-term objective is increasing CBT-CP availability, especially for communities affected by the opioid crisis. Our aims: 1, In a planning phase, refine strategies to identify and recruit patients, finalize intervention procedures, and ensure data infrastructure and quality. 2, Determine the primary outcome of effectiveness of online and telephonic CBT-CP on patients' pain severity and secondary outcomes including depression, sleep, quality of life, and pain-related healthcare utilization from the electronic health record. We will examine patient and system factors that reduce pain severity and the role of theory-based mediators such as catastrophizing and self-efficacy; as well as conduct formative and summative evaluations to: understand, describe, and explain barriers and facilitators to intervention adoption, implementation and sustainability. 3, Assess the cost and incremental cost-effectiveness of online and telephonic CBT-CP compared to usual care. Our population is adults with high impact chronic pain who receive care in one four diverse healthcare systems. Eligible, consenting participants will be randomized to one of the two PainTRAINER interventions or usual care. Interventions will be 8 weekly, 45-minute sessions of the online program or telehealth-style phone coaching by trained behavioral health specialists. Self-reported pain severity and secondary outcomes will be assessed at baseline and at 3, 6, and 12 months. Regression models for longitudinal data allowing interactions between assessment time and randomization arm will be used to estimate intervention effects at 12-months, the primary endpoint This project addresses national priorities including identifying effective, low-cost, low-risk care models for pain management, especially behavioral treatments for self-management that are readily implemented and disseminated. If effective, online and telephonic PainTRAINER CBT-CP have the potential to spread nationally, similar to phone interventions for tobacco cessation and weight loss, to reduce the personal and economic burdens of chronic pain.