A Q&A with Alicia Heapy, PhD and Diana Higgins, PhD

Co-operative Pain Education and Self-Management: Expanding Treatment for Real-world Access (COPES ExTRA)

Alicia Heapy, PhD, is a health services researcher at the Center of Innovation for Pain Research, Informatics, Multi-morbidities, and Education (PRIME) and an associate professor at Yale School of Medicine. A clinical psychologist by training, Dr. Heapy’s research is mainly focused on nonpharmacological interventions for chronic pain, particularly psychological and behavioral interventions, including cognitive behavioral therapy (CBT), for chronic pain and using technology to increase access to those treatments. Diana Higgins, PhD, is a clinical psychologist at VA Boston Healthcare System where she is the director of Pain Psychology. Additionally, Dr. Higgins is an assistant professor at Boston University School of Medicine. Her research interests focus on nonpharmacological treatments for chronic pain, particularly on the utilization of technology-delivered treatments to help increase access to psychology-based interventions for chronic pain.

A:  

Alicia Heapy (AH):  In the COPES ExTRA trial, we're looking at two different ways to deliver CBT for chronic pain.  One way is delivered through technology and people can participate from their home; and in the other way, treatment is delivered by a VA clinician at a person’s local VA.  Both ways are evidence based, but the technology-based form of CBT is much easier for patients to do, so we think they will attend more treatment sessions and get better results. We're interested in understanding the relative strengths and weaknesses of these two treatments and how they work in the real world to deliver outcomes that we know are important to people who have chronic pain—things like managing pain that interferes with daily functioning, sleep, and quality of life.  We will be comparing the level of engagement and the outcomes that people get in these two treatments depending on some factors that we know have been associated with disparities in the past, like differences in sex or race.  We're also looking at outcomes among people who traditionally have been excluded from these types of trials, primarily, patients who have substance use disorder.

Diana Higgins (DH): We are using Interactive Voice Response (IVR) for the treatment pathway delivered via technology and we think it will really help to increase access to this care because provider capacity in the VA to deliver CBT for pain may not always meet demand and patients may experience barriers to access, such as transportation. Of course, availability varies across facilities, but we're hopeful that we can expand access to CBT interventions for pain through this technology.

A:  

AH: Right now, we are running this trial in nine VA sites around the country, enrolling a total of 764 veterans with chronic musculoskeletal pain.  Participants will be randomly assigned to either 10 weeks of treatment using IVR technology or 10 individual CBT sessions at their local VA (which could be in person, or, with COVID precautions, those sessions could be through video conferencing).  We're trying to be very broad with our recruitment and think about the patient who would present for chronic pain within the VA system clinically, outside of a trial. That would include any veteran who is experiencing chronic musculoskeletal pain very generally—it could be back pain, joint pain, osteoarthritis, fibromyalgia—and of at least moderate intensity (a four or greater on a pain scale of zero to ten, with ten being the worst pain imaginable).

DH:  We've also made efforts to make sure that patients with previous or current substance use are invited to participate in our trial, as long as they are not actively undergoing detox at the time.  This population is often excluded from trials examining CBT for pain.  In the past, some of these trials screened out those participants who have untreated substance use because the substance use usually takes precedence for treatment.  Often, even outside of clinical trials in the VA, pain clinics or other types of pain providers will not provide CBT for pain treatment while someone is actively using substances (and not in treatment) because those can be very treatment-interfering behaviors. That can mean that these patients have delayed access to this type of care for pain.

A:  

AH: COPES stands for Cooperative Pain Education and Self-Management.  It's a technology-based intervention with the primary purpose of increasing access to CBT.  We already know that CBT works, it is an evidenced-based intervention for chronic pain, but there are barriers to access, like living where there are not many providers with CBT training and other travel limitations, as well as having work and family commitments that make it difficult for them to come in for treatment during usual business hours.  This technology really helps address those limitations so that more people can engage in this intervention. COPES is delivered through technology, so people can participate in it in their home, with the same tools that people learn in in-person CBT, but just in a slightly different way.

Patients get a workbook and a pedometer. They learn one new pain coping skill each week, and they are asked to do three tasks each week: 1) practice the skill that we taught; 2) increase their steps; and 3) make their own goal to do something meaningful or important to them.  Our Interactive Voice Response (IVR) system calls them each day and asks them seven questions about their pain, their sleep, their skill practice, and their steps. Then once a week, a coach reviews all of the data that the person has reported via our system and records a personalized feedback message that the participant or patient can listen to at the end of each week.  That message gives patients encouragement and reinforcement for their effort, helps them notice patterns, and just basically helps them stay on track.

A:  DH:  The prevailing approach to thinking about chronic pain is that there is a biological basis to pain that involves the brain and other parts of the nervous system, and then there are some psychological and social components. I know people often think mental health and psychological are synonymous, but I want to broaden that to encompass behaviors, thinking patterns, emotions, and social context.  Social context includes things such as a person’s family unit, whether they work or not, and the community in which a person lives. All of these components tend to play a role in someone's chronic pain experience.  In psychologically-based interventions—I'm going to focus on CBT for pain—we address a lot of different factors in a person’s life with the hope of reducing pain intensity, improving functioning in these different areas, and improving their quality of life. For example, we talk about their activity level and whether or not they avoid activity out of fear of pain, and we find ways to promote some physical activity. We talk about sleep, because people with chronic pain often report sleep disturbance. We also talk about mood symptoms because feeling anxious or depressed can make chronic pain seem much bigger and much more significant in someone's life and pain can worsen depression and anxiety symptoms. We talk about thinking patterns. Something very common in chronic pain is called catastrophizing, which means assuming the worst possible outcome. So, these approaches can address a broad range of functioning that we think are important to people's lives in general, but certainly are effective for managing chronic pain.

AH:  I think what may not be as well understood is that in psychology-based interventions, we teach evidence-based tools so that people can learn to help themselves by taking steps to manage their own pain. So, for patients who aren't interested in medications, for whatever reason, they can use these tools. Even among patients who are taking medications, very often we find that medications will help, but there'll be some portion of the pain that is still left, and that pain interferes with their quality of life and functioning. These tools can help people manage their pain so they can do more of what they would like to be doing, despite pain.

A: 

AH: When hearing about or considering this type of treatment, people sometimes wonder, "Well, how could this psychological intervention fix my physical pain?" If the answer to that is not explained well, people may start to feel that a referral to this type of treatment means that their clinician thinks the pain is in their head, or a mental health issue.  So, there is a lot of work to be done in educating people that these types of interventions can't fix your back, or won't repair your osteoarthritic knee, but can really help you manage the situations and behaviors that make your pain worse and help improve your functioning so that you do feel better.  Often, psychology-based intervention is introduced into a treatment plan after surgery didn't work or medication didn't take as much pain away as one would have liked, so it starts to seem like the consolation prize.  There is also reticence for some clinicians recommending it, as they may wonder, "Will my patient receive this referral to a psychological approach well or will they think that I'm offering it to them because I don't believe their pain is real?"

Access is another issue; it’s one of the factors that led to the development of COPES IVR-based CBT since we know that patients may have a hard time accessing in-person CBT for chronic pain.  CBT often requires weekly visits for eight to 12 weeks and that can be difficult for patients. They may have travel or schedule limitations, and/or work or family care obligations, which may make it difficult for them to consistently come to treatment. When physicians believe that a patient might have a hard time committing resources to in-person behavior-based interventions, they may be reluctant to recommend it.  This can lead to falling back on more medication-based interventions, injections or other less time and travel-intensive approaches.

DH: I definitely agree with Alicia that it doesn't bode well for patients to engage and benefit from the treatment if it is presented as a last resort.   It's better when presented as part of a pain care plan among other treatments, or by itself as a first-line treatment as has been recommended.  It's also important to distinguish that this treatment is not only for patients with mental health diagnoses. There’s a false sense of how we use this treatment because, frankly, we can use it for any patient with chronic pain who needs some additional help with improving their functioning and their quality of life. It doesn't have to only be patients who have mental health conditions as well. I think it's very important to emphasize to providers that they should talk to their patients about why they're being referred to a psychologist so they are not expecting to receive a different type of pain treatment, like medication or an injection, especially when they are referred to a psychologist who works in a pain clinic.

A:  

DH: Patients who are referred to a psychologist, or other CBT provider, for pain worry that their providers don't believe them anymore, and that the pain is “only in their heads” because they're seeing a psychologist. So, first-line providers can start with explaining their reasons for the referral and a bit about what CBT is.  I find that the patients who have some familiarity with CBT are more likely to engage and get more out of it when they come for CBT for pain.

 

AH: As Diana said, awareness is increasing, but I think people are not as aware of CBT as an intervention for pain as they are for, say, surgery, medication or physical therapy. Often people, including clinicians, will search for a cure that's medically based, and behavioral or psychological intervention may come later, which is unfortunate because patients may benefit even more if psychology-based interventions are introduced at an earlier time so they can avoid some disability or distress that goes along with having pain for a long period of time.  We really want people to understand that through CBT, the goal is to help them get back to doing the activities that are meaningful or important to them, so it resonates.  Having referring providers describe the intervention clearly and explicitly is the best way to reduce barriers and increase adoption.

A:  

AH: Most people are familiar with IVR as the automated voice prompts and scripts utilized when calling a pharmacy, insurance company, or bank.  At their very basic level, these systems take in information provided by the user’s voice or telephone keypad to answer prerecorded questions.  Users can also receive information through prerecorded messages or other forms of scripted information. We use both of those in our IVR system; however, we worked very hard to make our IVR system better than those systems.


We have an actual person voicing all of the prompts on our system, so, it's not a computer-generated voice, and I think people really like that. For our trial, participants get a short (90 seconds to two minutes) call each day at a time they pick where they answer seven questions about their pain, their sleep, their skill practice, and their steps.  Since the IVR system calls them, patients don't have to think about making a phone call every day, so it’s easy. We have found that in our prior trial, people answer about 90% of these calls  for the full duration of the trial, and it's pretty consistent from week to week. People tell us that it helps them stay on track and they find the feedback from their coach valuable and feel motivated by being able to report on what they have done, the steps they have taken, or the pain coping skill they practiced. By paying attention to their pain, their sleep, and how their pain responds when they use the skills they’ve learned, they may see, with their coach's prompting, patterns about what they did on the days when the pain was really low, or those days where they slept well by using skills learned.  We've always felt very strongly that patients will not answer a call every day if they don't see that someone is paying attention to the information they give.  So, we are very committed to giving them feedback that incorporates everything that they're telling us.

DH: The personalization component is one of the things that keeps patients engaged. They like to hear very detailed, but short, informational messages about how they've done over the previous week, especially those patterns where we can help them think outside the box about how to manage pain. While these messages are pre-recorded and not occurring in real time, they are still personalized to the patient.

A:   DH: There are a number of internet-based programs out there that are focused on psychological and behavioral treatments for chronic pain, and sometimes physical therapy, and they are all a bit different in approach, so I'll speak from my own perspective about the program that I developed, along with others, that uses content from COPES.  I've worked on Alicia's COPES trials for many years. There are different approaches to developing and delivering these internet-based programs. Some of them are guided by clinicians, and that can take lots of forms: a weekly phone call with the psychologist, personalized text messages, personalized feedback from a coach on how a person is doing with their skills practice.  Other programs are entirely self-guided, meaning there's no clinician contact.
The one that we developed is self-guided since, at that time, we didn't really know what the benefit would be, but we knew it would be more cost-effective, efficient, and easier to disseminate broadly if we didn't have to rely on contact with clinicians. Like many other programs, this one, which was developed for veterans with low back pain, provides information about CBT skills for chronic pain presented through several formats such as audio, video demonstrations, diagrams and photos to help demonstrate skills.  It also gives some personalized feedback about the knowledge acquired throughout the program, which helps tailor the programs to meet individual needs. I think most of the trials of these internet-based programs have shown some efficacy for pain-related outcomes, and other related outcomes, such as improved mood or better mobility. We don't really have a sense of what helps keep patients engaged in the programs, so that will be the next wave of research, and we'll see what that brings to light.

A:  

AH: We've focused mostly on access disparities. The COPES approach to treatment is really helpful for people who have travel or schedule barriers or live in an area where they don't have access to trained clinicians. This type of treatment through technology really increases access, but there are still barriers.  Some people don't have access to technologies like internet connections or devices that would allow them to engage in internet-based interventions. There are some people who don't feel comfortable using technology, or there may be some people whose living situations don’t give them the privacy to stay engaged or feel comfortable disclosing information in a videoconferencing visit in their home.  There is no singular intervention that can address all barriers, which is why I feel like it's very important for the VA (and other health facilities) to offer a menu of treatment options and modalities for people. That way, hopefully, everyone is able to find something that they're able to engage in and get benefit from.

DH: I think COPES has a bit of an advantage over some of the other treatments (like the VA Video Connect visits and the internet-based interventions) because COPES doesn't require that patients have internet access.  Even if a patient has access, the internet quality, or bandwidth might be very poor. It's difficult to deliver treatment under those circumstances.  So, using the telephone, which most people have access to, really does help reduce that particular barrier and I think that's important. The phone is also very accessible for older patients, for patients who may not have consistent housing, or for patients who live in rural areas where there isn't internet access or it's very slow.

A:   AH: Like most trials, COVID had some effect on our trial, but we were lucky in that the impact was moderate.  We planned on comparing two treatments: one that patients could do totally from home, and one where patients had in-person visits.  After COVID hit, pain care, along with most of the care in the VA that wasn't emergency care, shifted away from in-person visits.  So, then people who were in what we used to call the in-person treatment arm of the trial began getting CBT via synchronous videoconferencing.  This allowed the trial to continue and still offer patients real-time, live treatment from a local practitioner, but just by way of VA Video Connect or other videoconferencing options.  Even though these are both technology-based interventions, there's still a difference since IVR is totally asynchronous, which means that the patient can access the call at any time and it doesn't require a full 50 minutes, as most typical treatment sessions do. With VA Video Connect, the treatment is conducted during business hours and it still takes about 50 minutes. For patients who are randomized to receive local treatment or asynchronous treatment, we're able to track whether they get actual in-person visit or if they get the live videoconferencing visit. We'll continue to track that because we imagine that slowly in-person treatment will resume, but some proportion of patients will continue to get video treatment.  I see this as an opportunity for us to learn a little bit more about different types of technology-based treatments.

DH:  The access to the VA Video Connect is limited by the quality of internet that any given patient has, or we have older patients who are just not technology savvy, which means that a good proportion of care ends up happening over telephone.  A 50-minute phone call is a long time to spend on the phone. Certainly, there are telephone treatments that have demonstrated efficacy for addressing chronic pain, but I'm wondering if there wasn't sort of a change in the style of treatment delivery when we, as clinicians, shifted suddenly to providing remote clinical care (whether by phone or Video Connect) during the pandemic.

A:  

AH: We know that veterans experience higher prevalence of pain and more severe pain than non-veterans. They frequently have co-occurring physical and mental health conditions that can complicate treatment, so I feel like this is a population that's been especially impacted by chronic pain and is in need of study.  In terms of nonpharmacological interventions, pain care has changed quite a bit in the past few years, moving away from long-term opioid treatment because of the known harms.  This is quite beneficial, but in addition to moving away from certain things, we need to be moving toward other modalities that can offer patients evidence-based benefits. Nonpharmacological interventions represent a large number of effective treatments that patients have the option of participating in, so it's really an opportunity to learn about what works for whom, how to implement these treatments so that most veterans can get benefit from it. I find this aspect particularly impactful and meaningful in the setting of the VA and with veterans—that is where I and Diana both have spent our entire career working.

DH: I think Alicia's response is perfect.  I would echo everything that she said. I think that helping to promote nonpharmacological treatments, particularly things like psychological and behavioral treatments, as an important part of veterans' pain care plan is an important next step.  The VA has certainly made big efforts in this direction over the last several years, but I think we could continue working toward improvements. Being part of the Collaboratory helps highlight this research as an important next step.

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