The proposed study is the first effort to test a manualized cognitive-behavioral therapy
intervention for chronic pain delivered by behavioral health providers working in primary
care clinics. If successful, findings from this study will inform Defense Health Agency
(DHA) policy nationwide. The study teams' DHA collaborators write these policies and the
PIs are active participants in the DHA MHS Stepped Care Pain Pathway workgroup. Data from
this study will inform military, VA and civilian primary care services about the
contribution of integrated behavioral health pain management to pain outcomes, healthcare
utilization, and satisfaction with care.
The purpose of this randomized pragmatic trial is to assess the effect of monthly booster
contacts on long-term Brief Cognitive Behavioral Therapy for Chronic Pain (BCBT-CP) pain
outcomes compared to BCBT-CP without a booster in 716 Military Health Systems (MHS)
beneficiaries referred to a Behavioral Health Consultant (BHC) for pain management using
BCBT-CP.
Active Comparator: Standard BCBT-CP
Brief Cognitive Behavior Therapy for Chronic Pain (BCBT-CP) is a seven-module
intervention for chronic pain based on the efficacious specialty-care, ten-session
version of this treatment called Cognitive Behavioral Therapy for Chronic Pain (CBT-CP).
CBT-CP has been disseminated throughout the VA healthcare system as a manualized,
non-pharmacological intervention for chronic pain (Stewart et al., 2015). Preliminary
studies of CBT-CP found that most patients completed all ten CBT-CP modules (Stewart et
al., 2015) and better outcomes were associated with home-based skills practice (Edmond et
al., 2017). One study of CBT-CP in the VA found that over 50% of patients who were
offered the treatment declined and individuals with a history of opioid use were
under-engaged for this efficacious treatment (Higgins et al., 2018). Thus, the DHA
abbreviated CBT-CP to only seven modules for implementation in primary care, where most
patients with pain are seen (including those with active and past opioid use). The seven
modules are:
(A) Assessment, engagement and goal setting, (B) Education on chronic pain and relaxation
training, (C) Discussion of the importance of activity engagement and pacing, (D)
Progressive muscle relaxation and guided imagery, (E) Identifying thoughts that
negatively impact pain, (F) Modifying thoughts that negatively impact pain, and (G)
Developing an action plan.
Patients are encouraged to complete a minimum of four modules with their provider (i. e.,
A, B, G, and at least one additional module). BCBT-CP was developed in collaboration with
the developers of CBT-CP to establish a brief version of protocol suitable for delivery
by BHCs working in MHS Primary Care clinics.
Each module appointment lasts approximately 30 minutes and includes the following
treatment components:
Introduction to the module and confirmation of session agenda Check on mood and
completion of patient measures (DVPRS, PEG-3, BHM-20, PHQ-9, PCL-5) Review of material
from previous modules, including home practice Introduction of the new material and
answer questions Module wrap-up BHCs are trained by the DHA on how to effectively
introduce and "sell" BCBT-CP to patients and have access to supplemental and appended
materials to address comorbidities.
BCBT-CP Booster Contacts are intended to refresh BCBT-CP content without introducing new
skills. To accomplish this, Booster Contacts are manualized (see appended Booster
Protocol form) to cover: assessment of pain since last BCBT-CP appointment, refresh
BCBT-CP module content, and remind about next BCBT-CP appointment.
Booster contacts will be scheduled 1-week following each BCBT-CP module. Booster contacts
will occur at least one week after a BCBT-CP module but no more than 2 weeks after a
BCBT-CP module. Following completion of care on the BCBT-CP pathway, booster contacts
will continue monthly through month 12 of study participation. Depending on how often the
BHC can meet with the patient-participant to receive module care, participants could have
a varying number of booster calls, but based on the investigators' pilot study when
patients could only meet with their BHC on average once a month, the investigators
believe that most patients will receive 12 booster contacts. The booster contacts may
occur via telephone or video conferencing and will be audio-recording using and
independent device (separate from the conferencing platform, e.g. Zoom).
All Booster providers (research staff) will receive a two-hour training on conducting
Booster Contacts from the study PIs including description of how to complete the BCBT-CP
Booster Protocol Form.
National data pull for will include healthcare utilization data for all individuals with
identified musculoskeletal pain treated in the Military Health System in a clinic with an
identified BHC trained to provide BCBT-CP between Jan 2018 and Dec 2024. The data pull
will be coordinated in collaboration with the Defense Health Agency and the Uniformed
Services University Center for Rehabilitation Sciences Research. The group will complete
a DRT request to identify data items to collect, establish a data management and transfer
plan (including a plan for deidentifying data) and an analysis plan (analysis to complete
with collaborators at Harvard Medical School).