Telehealth CBT to increase engagement in pain treatment among Veterans using prescription opioids

背景：长期服用阿片类药物的慢性疼痛和负面后果与公共健康有关 与严重功能障碍、高度精神疾病共病和早产相关的担忧 死亡率，特别是在退伍军人中。阿片类药物处方和疼痛的临床实践指南 管理层建议使用非药理学方法作为一线治疗。心理社会 干预措施(例如，认知行为疗法)有强有力的证据支持他们改善疼痛的能力 结果。患者对心理干预、阿片类镇痛剂、 除其他外，心理社会干预改善疼痛的能力会极大地干扰患者的能力 启动和维持对心理社会干预和其他非药理学方法的参与。 意义/影响：如果没有协调一致的努力来影响阻碍参与治疗的信念， 可能从治疗中受益的退伍军人将不会得到治疗。这可能会导致持续的负面风险 与长期阿片类药物治疗和疼痛管理不足相关的后果。认知型- 寻求治疗的行为疗法(CBT-TS)是一种循证干预，直接干预 关于那些阻碍治疗开始和保留的信念。通过干预这些信念，这项研究 有可能提高对心理社会疼痛干预和其他非药物干预的参与度 疼痛治疗，这将改善与疼痛有关的干扰和功能，并减少对阿片类药物的依赖 止痛药。本研究涉及VHA/VA退伍军人护理的优先事项，包括阿片类药物的使用、疼痛控制和 获取和直接解决高铁与发展服务导向研究的定向征集的优先事项 阿片类药物安全与阿片使用障碍。 创新：拟议的研究是CBT-TS首次应用于患有慢性疼痛的退伍军人 接受阿片类镇痛剂--这是一个特别高风险、对治疗有抵抗力的人群。这是第一个直接研究 对心理社会干预的想法进行干预。 具体目标：具体目标是：测试CBT-TS的效果，以增加心理社会的启动 对接受阿片类镇痛剂治疗慢性疼痛的退伍军人进行疼痛干预(目标1)，测试 CBT-TS增加接受阿片类药物的退伍军人在心理社会干预中的疼痛留存率 慢性疼痛的镇痛剂(目标2)，并评估CBT-TS在改善疼痛和物质使用方面的效果 接受阿片类镇痛剂治疗慢性疼痛的退伍军人的结局(目标3)。我们还将测试以下各项的效果 CBT-TS关于其他非药物止痛治疗的启动和保留(探索性目的)。 方法：参与者(N=300)将被随机分配到CBT-TS条件或接受教育 控制条件。在这两种情况下的参与者都将完成对疼痛、治疗参与度、 在基线以及治疗后1、3和6个月时使用阿片类药物，以评估初级、继发性和 探索性结果。 实施/下一步：这项研究的结果将提供有关增加 参与针对疼痛的心理社会干预，这可用于为今后的执行和 传播努力。研究小组将与VHA国家疼痛管理和阿片类药物安全合作 办公室和VHA以患者为中心的护理和文化转型办公室，以确定实施和 传播努力。CBT-TS目前正在进行提高心理健康水平的实施研究 这一努力也可以扩大，以增加心理社会的治疗参与度 疼痛干预和其他非药物疼痛治疗。

Background: Chronic pain and negative consequences of long-term opioid therapy are related public health concerns associated with significant functional impairment, high psychiatric comorbidity, and premature mortality, particularly among Veterans. Clinical Practice Guidelines for opioid prescribing and pain management recommend using non-pharmacological approaches as first-line treatments. Psychosocial interventions (e.g., cognitive-behavioral therapy) have strong evidence supporting their ability to improve pain outcomes. Patient beliefs about the stigma associated with psychological interventions, opioid analgesics, ability of psychosocial intervention to improve pain among others can greatly interfere with the patients’ ability to initiate and maintain engagement in psychosocial interventions and other non-pharmacological approaches. Significance/Impact: Without a concerted effort at affecting beliefs that impede engagement in treatment, Veterans who may benefit from the treatment, will not receive it. This can result in continued risk for negative consequences associated with long-term opioid therapy and inadequate pain management. Cognitive- Behavioral Therapy for Treatment Seeking (CBT-TS) is an evidence-based intervention that directly intervenes on beliefs that act as barriers to treatment initiation and retention. By intervening on these beliefs, this study has the potential to improve engagement in psychosocial pain interventions and other non-pharmacological pain treatments, which will improve pain-related interference and functioning and reduce reliance on opioid analgesics. This study addresses VHA/VA Veteran care priorities including opioid use, pain management, and access and directly addresses priorities of the HSR&D Targeted Solicitation for Service Directed Research on Opioid Safety and Opioid Use Disorder. Innovation: The proposed study is the first application of CBT-TS for Veterans with chronic pain who are receiving opioid analgesics–a notably high-risk, treatment-resistant population. This is the first study to directly intervene on thoughts about psychosocial interventions. Specific Aims: The specific aims are to: test the effects of CBT-TS to increase initiation of psychosocial interventions for pain among Veterans receiving opioid analgesics for chronic pain (Aim 1), test the effects of CBT-TS to increase the retention in psychosocial interventions for pain among Veterans receiving opioid analgesics for chronic pain (Aim 2), and evaluate the effects of CBT-TS in improving pain and substance use outcomes among Veterans receiving opioid analgesics for chronic pain (Aim 3). We will also test the effects of CBT-TS on the initiation of and retention to other non-pharmacological pain treatments (Exploratory Aim). Methodology: Participants (N = 300) will be randomized to either the CBT-TS condition or an education control condition. Participants in both conditions will complete assessments on pain, treatment engagement, and opioid use at baseline, and 1-, 3-, and 6-months post-treatment to assess primary, secondary, and exploratory outcomes. Implementation/Next Steps: Results from this study will provide critical information on increasing engagement of psychosocial interventions for pain, which can be used to inform future implementation and dissemination efforts. The research team will work with the VHA National Pain Management and Opioid Safety office and the VHA Office of Patient Centered Care & Cultural Transformation to identify implementation and dissemination efforts. CBT-TS is undergoing current implementation research to increase mental health functioning and this effort could be expanded to also increase treatment engagement of psychosocial interventions for pain and other non-pharmacological pain treatments.