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Marc Rosen (MR): When Veterans apply for service connection, which is a financial remuneration benefit somewhere between disability and workman’s comp, we wondered, is this a point at which they can be engaged in addressing the underlying problem? That’s the question that this study asks. Fairly early in developing the pilot study, I talked with Steve about using motivational interviewing as a tool to engage Veterans in pain-management-related services when they seek service connection. We planned to address the topics in sequence: talking about service connection and the condition they’re seeking service connection for, and then transition to other topics related to their pain and its impact on their lives. Since we both believe in VA health care, it’s really simple to promote VA treatment to Veterans who are applying for service connection for a painful condition.

Steve Martino (SM): I have a background in doing Screening, Brief Intervention and Referral to Treatment (SBIRT) interventions and so I collaborated with Marc on his original pilot study examining the application of motivational interviewing to engage people in multimodal pain care. As we explored how we would construct this intervention to fit the broad VA healthcare system, we decided to apply the approach in a hub and spoke model, centralizing the project and delivery of counseling within VA Connecticut and then out to the other New England VISN medical centers. The compensation and pension system (Comp & Pen) seemed to be a really advantageous place in which to meet Veterans where they’re at. A lot of the Veterans coming in for service connection have not been engaged in the VA system–and have not had long careers with managing their pain—so using Comp & Pen as an access point to inform Veterans about the healthcare system provides an opportunity to get Veterans help sooner.

Our goal is to enroll 1,100 participants over the course of the trial. Participants receive four sessions of the counseling intervention within 12 weeks, and then an additional booster session between weeks 12 and 32.  All eight medical centers in New England are participating, with the VA Connecticut being the hub for providing the counseling.

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MR: SBIRT stands for Screening, Brief Intervention and Referral to Treatment. In our trial, the screening is brief since we already know that the Veterans are presenting with a musculoskeletal pain claim. It introduces the counseling, as part of a discussion about their claim and the precipitating condition for the claim. The Veteran reviews briefly what their claim was for, the pain condition that they have, and what treatments they have tried. Using motivational interviewing, we assess the extent to which they are interested in other treatments that they may not have considered or may not have tried. If they are interested, we make an action plan to help the Veteran access those treatments.  We then pivot to a discussion of substance use. We introduce the concept that people with pain often take drugs or alcohol to deal with the pain and ask the Veteran if they are willing to talk about their substance use. Then we do a bit of screening for the extent of substance use, and, if indicated, we try to motivate the person to address their use.  The counseling is by phone up to four sessions—well, five, post-COVID.

SM: I would add that another component of SBIRT is a light touch of case management. Since this is a pragmatic trial, our counselors need to communicate with providers as would usually occur in the healthcare system.  This means that our primary means of communicating with the providers who place the consult is through Computerized Patient Record System (CPRS). An important aspect of all the sessions is to place a note within the CPRS that indicates what services the Veteran has expressed interest in receiving. In this note, the counselor requests that the primary care team, usually the Patient Aligned Care Team (PACT), discuss the services with the Veteran, considers the priorities within a pain care pathway, and refer to pain management, mental health and addiction care, as needed.  In their follow up sessions, the counselors revisit how things are going, what services a Veteran may have accessed, and what barriers they’re experiencing.  Those barriers could include that the Veteran has yet to enroll in VA care or that they’re waiting for their first appointment in primary care, or any number of things.  The counselors problem solve with Veterans along the way to help ease access to services and to sustain motivation since often things don’t move quickly.

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MR: Motivational interviewing starts with the presenting issue, and then goes on to amplify the Veteran’s concerns, motivations, and reservations, and discuss what they’ve tried and what they haven’t tried.  Then the process moves to creating a plan. Other elements of motivational interviewing are empathy and compassion, as well as listening in an open-minded, supportive way. That combination is surprisingly powerful. Motivational interviewers never tell you what they think about your substance use or other issues since, to some extent, part of the stance of the motivational interviewing is to accept the patient’s perspective.  So, if someone tells you that alcohol calms them down, and helps them sleep, and is the only thing that works for their anxiety, the job of the motivational interviewer is to look at the situation through the patient’s lens and say, “So you feel that alcohol is a helpful medication for you?” Usually, there’s a little bit of irony and exaggeration because the Veteran didn’t say that he’s using alcohol as a medicine; he simply said it helped him sleep. But maybe that prompts the Veteran to say, “Well, I know it’s not a medicine.” In this way, the ambivalence is brought out and interview steers towards changing to a healthier behavior.

This kind of brief intervention is classically done when people come to the emergency room after an accident.  While there, someone assesses them for substance use and suggests that maybe this accident is a reminder that their substance use is a problem. Or someone comes to an internist appointment for a medical condition, and addiction gets addressed because of its impact on the patient’s medical condition. Motivational interviewing can be used to transition people from their presenting issue an underlying condition such as addiction. Steve has been promoting motivational interviewing for years, which is part of why it was top of mind when we thought about how to make service-connection exams into therapeutic encounters.

SM: A change in certain behaviors could lead to less pain, better functioning, and hopefully an improved quality of life. In motivational interviewing, if we see that some aspect of a behavior is problematic—even if the patient isn’t presenting it as a problem—our job is to try to bring that forward and help them come to see it for themselves. That’s the evocative side of motivational interviewing and that’s what makes it more sophisticated than how it’s often described; it is a subtle, nuanced, language-sensitive approach to try to hear what might motivate people individually and uniquely. Within all people, there are motivations for making changes. In an area where there is a chance for improved behavior, we feel justified in guiding someone towards that behavior adoption, even if initially that wasn’t necessarily where they were thinking they were headed.

I think the key is that we are listening carefully and attentively to the ways in which substance use (whatever that may be) or a lack of engagement with pain management services may be causing a person some difficulties. Veterans are used to enduring pain and they often will try to avoid seeming weak and revealing their pain.  Having the experience of being heard increases the chance that they might reveal some of their struggles that they otherwise might not have readily put forward. It’s an important component, that sensitive, person-centered approach to allow a conversation to unfold.

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SM: Our entry criteria for the trial is that people are experiencing moderate to severe pain and, for most people, this pain is interfering with their functioning in important facets of their lives.  For most of our participants, they have some degree of interest in learning about services—and most indicate interest in pursuing some options for pain management that they might not have tried before.  Substance use, I think, becomes trickier motivationally, since we are not specifically recruiting people with bonafide alcohol, drug, or medication problems. We are recruiting them based on their pain, but we are picking up people who might not have been thinking about their substance use as problematic. Our counselors need to be deft in their capacity to motivate that behavior change, as well.

MR: The pilot study we did before the trial worked better than I had anticipated. I’m used to working in addiction where sometimes treatment is a hard sell, especially in a specialized addiction clinic where you get a lot of people who’ve had addiction for a long time.  In the pilot study, we were taking people early in the course of their pain condition.  These patients, who are relatively treatment-naïve, can benefit a lot from some basic treatment.

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MR: Being in pain is miserable enough, and when people experience pain for long enough, it’s so frustrating that people are willing to take gambles that they might not take otherwise. A lot of the nonpharmacologic pain treatments, like cognitive behavioral therapy (CBT), reduce pain severity and can lessen the interference of pain with other activities, but doesn’t eliminate the pain completely.  Drugs offer the promise of pain relief and temporarily provide it; however, a lot of the side effects and problems with the medications are subtle and their impact can go unnoticed.

For instance, the company that makes gabapentin, which was marketed for general pain, subsequently paid a large penalty because in control trials it apparently doesn’t work for general pain. It works for neuropathic pain, a specific type of pain, but it became aggressively marketed for all kinds of pain.  In popular opinion, and in a lot prescribers’ minds, gabapentin was viewed as a good general pain medication. As a prescriber, I thought, “Well, this is a really safe drug. It’s pretty hard to overdose on it. It doesn’t have any of the side effects that kill people or that are difficult to monitor. You’re not going to damage someone’s liver.”  There are a lot of drugs that are toxic and dangerous, and risky, and gabapentin isn’t. When people are in distress and these drugs are being marketed to them, the drugs get oversold and the downsides don’t get enough attention. The downside of gabapentin is that it’s somewhat sedating and makes people a little bit dizzy, so if you give it to enough people you will likely see that more people taking it will get in car accidents, and more of them will fall. If they drink or use other drugs with gabapentin, they’re more likely to die. So, you have these subtle, longer-term effects.

SM: That’s where our introduction of the biopsychosocial model comes in—as well as our efforts to broaden the perspective of how we approach managing pain.  By pulling from different arenas of health care services and putting them together in a treatment plan, we will hopefully help Veterans obtain better outcomes.

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MR: Comp & Pen is a separate part of the Veterans Administration that manages service connection claims, adjudication, and examinations. This project has involved making a connection to that other part of the VA. The VA has a healthcare system and an indemnification/workman’s comp/disability system. The budget for each of them is comparable, but research overwhelmingly resides in the healthcare system. Doing research across both systems has involved creating collaborations with the Veterans Benefits Administration as well. So, that’s taken time, effort, and communication with people with whom we don’t ordinarily work.

SM: One of our main challenges is accessing databases to identify Veterans who are scheduled for examinations. Those entries come via in-house examinations within the VA medical centers or through Comp & Pen exams. We thought our initial database captured both sources of data, and, in the beginning, we did have both sets; however, during the course of implementing the trial, there was a move towards more contract exams, and we didn’t realize that the database we were using wasn’t capturing that migration.  It took a lot of work by our project director, Christina Lazar, who was successful in locating a database that was much more comprehensive and allowed us to access a greater pool of Veterans who were being scheduled in the New England region where we are recruiting.

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SM: In the initial phase of the grant, which was the UG3 phase, we learned a great deal as we went around to the various Comp & Pen offices and mental health and integrated pain clinics. Particularly, we found that Comp & Pen is not integrated into the general services and coordination of care was affected. A lot of Veterans coming through Comp & Pen did not know what services were available to them, and a lot of the providers didn’t know what the best pain care pathway was. Our counselors became a critical juncture for bridging this gap from Comp & Pen to the VA healthcare system.

In addition, we have found that some sites or providers are more conscientious in making sure that they are having discussions with Veterans about pain management and some sites or providers who may not accept the notes from our counselors as readily as others. We have had to get to know one another in a pragmatic trial that wasn’t trying to tightly control all of that and work within these realities. Another challenge that we had to work through was the familiarization of our counselors, who were working in different sites, to the unique settings within each participating health care center.  Not all sites offer the same services, so we decided to assign counselors to concentrate on certain sites in order to become more expert in what their sites had to offer, and to stay on top of the changes that were happening in the midst of the pandemic, such as creation of virtual options or when in-person visits became available again.

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SM: Veterans have a lot of pain; the rates of pain are higher in the Veteran population than in the civilian population. Pain certainly overlaps with the opiate epidemic and the need to address that is a big problem. Ultimately, there’s an opportunity to use evidence-based treatments to be helpful to people in both arenas.

MR: It matters how someone copes with their pain and the options a person has to manage it. There’s a big difference between ineffective and effective coping strategies. As Steve said, we have an opportunity to help people find effective ways to cope with pain.

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SM: Marc and I are practical when it comes to doing research. PMC was an interesting opportunity to work in a Collaboratory of other researchers, sharing ideas and resources. It’s not just our research project team, it’s a broader team science comprised of many other investigators and resources provided by PMC³.  Working together adds value to what we’re all doing.  It’s been really helpful to have access to this high level of expertise, where everyone is bringing something valuable to the table.  We’ve benefited from that team, and we’ve contributed to the Collaboratory as well. When we encounter the unexpected, like a pandemic, we have a team of experts to figure out the impact on our trials and how to gather information that will need to be considered in altering our intervention and planned analyses to factor in pandemic impacts. Alone, this would have been difficult to do.  Initially, everybody had different ideas about it, but, in the end, we came up with a pragmatic way of trying to monitor the impact. Together, we’re collecting data that will potentially give us a chance to understand the ways in which this kind of curveball transpired in each of our trials.

MR: There are so many topics, and so many details and issues that we come across within this work, like measuring pain, pain relief, and receipt of pain services.  We are working with different agencies and providers, and different ways of transmitting information. There are a lot of topics that are complicated, and it helps to have national experts with whom you can consult quickly and they will tell you a definitive answer about what’s known about the topic. That is incredibly time saving. You could spend a lot of time looking up how to score the brief pain inventory, and you’ll find hundreds of references on it and figure out which is the most relevant one, and which version of the brief pain inventory to give, and how to score it—and you may not come up with the right answer. Or you can ask Alicia Heapy, Robert Kearns, Will Becker, and many others—and they will tell you in a few minutes and give you a reference.