A Q&A with Don McGeary, PhD, ABPP & CAPT Jeff Goodie, PhD, ABPP
Targeting Chronic Pain in Primary Care Settings Using Behavioral Health Consultants
CAPT Jeff Goodie, PhD is a board-certified clinical health psychologist, an officer in the U.S. Public Health Service, and he is currently a Professor in the Departments of Medical and Clinical Psychology and Family Medicine at the Uniformed Services University of Health Sciences (USUHS). He serves as the Director of Clinical Training for USUHS’s clinical psychology program that trains Army, Navy, and Air Force graduate students, as well as some civilian graduate students, to be clinical psychologists. Dr. Goodie’s primary research focus is in the field of integrated primary care, specifically looking at the primary care behavioral health model, which is a system of integrating behavioral health providers into primary care settings.
Jeff Goodie (JG): In this trial, we are looking to determine the effectiveness of a chronic pain intervention pathway that the Defense Health Agency (DHA), has rolled out. We are looking at one specific component of that pathway: the use of behavioral health consultants (BHC) to target pain within a primary care setting. The interventions that are being provided by the BHCs were adapted from researchers in the VA (although we're not directly collaborating with them on this project).
This is the first time that we're looking systematically at the impact of using BHCs to target pain in primary care within the DOD. We've done a pilot study in one location and with one BHC to see if we were going to be seeing any effects at all. In the first phase [UG3], we did see some reductions in pain reported by the patients, but after individuals stop seeing the BHC, patient reports of pain intensity tended to go up. For the UH3 phase [the second phase of the trial], we are looking to see if a booster contact will help to sustain some of the reductions in pain that patients reported when they were being actively seen by the BHCs. In those booster calls, we're drawing on techniques from motivational interviewing to help enhance the likelihood that patients are engaging in the types of interventions that the BHC has already discussed with them and/or having those patients come back to see the BHC for follow-up appointments if those were part of the plan.
Don McGeary (DM): This trial has been guided by feedback from our stakeholders at various levels. When we did our focus groups with our patients, we talked to them about some of the putative mechanisms that they thought might be driving the drop off in reported pain reduction. Patients spoke about forgetting some of the information that was covered, as well as their appointments, and so they asked for reminders. In a way, the mixed methods design that these PMC studies are implementing allowed us to create a bespoke solution for some of the problems that we identified in the initial pilot phase. We also spoke with stakeholders in the DHA who helped guide our strategies for developing and delivering booster contacts as a mechanism for reminders and reinforcing clinical content. It was a group effort, which is a strength of pragmatic trials with strong stakeholder engagement.
JG: In the framework used by the BHCs, the appointments are broken up into modules, each with a different focus. One module is really about assessment, engagement, and goal setting. Then there's a module on education and relaxation training. There is also a module on activities and pacing and another module on relaxation training. Two modules are focused on cognitive coping. Finally, there is a module that is focused on the action plan. Each of the appointments with the behavioral health consultant lasts approximately between 20 to 30 minutes. In that first appointment, the modules would be introduced along with assessment, engagement and goal setting. If the BHCs are following the plan the way that it's laid out, all patients would receive what's called Module A (assessment, engagement, and goal setting) and Module B (education and relaxation training). Then, they'd get at least one of the other modules that I talked about: the activities and pacing module, the relaxation training module, or one of the cognitive coping exercise modules. Everybody would also get the action plan module. If this plan is followed the way that it's set out, patients would get a minimum of four appointments and as many as seven. Since this is a pragmatic trial and we, as a study, do not intervene in terms of saying what patients should be getting or need to be getting, there are variations in how many appointments patients are getting. We do conduct some additional assessments specifically for research purposes and the booster calls are completed by our research staff.
JG: We're also offering Fitbits for the first couple of hundred of patients for us to look at activity levels. While we encourage them to use the Fitbits, people can choose not to use them. We're only using the data in a sub-sample. Otherwise, we are staying low tech. We are administering our assessment measures for the study electronically and using the phone to call patients, but that's it.
DM: The goal is to use whatever technology is widely available in the military health system right now. As Jeff was describing, the goal is not to get too fancy. This is a nationwide effort from the DHA, so we want to make sure whatever we do in a large, well-resourced military treatment facility (MTF) can be done in a smaller clinic out on its own somewhere. Because of that, you want to keep the technology profile relatively low.
JG: There are multiple ways to get to the BHC, and it really varies by clinic. Maybe a patient is seeing a medical provider who then refers them over to the BHC. It may be that the BHC is the one who identifies the chronic pain piece, and maybe that isn't even the original reason for the BHC referral. For example, the person was referred for depressive symptoms, and in the context of that appointment, chronic pain is identified or raised as an issue. There may be opportunities for patients to self-refer to the BHC. The aim is to increase access to the BHC as much as possible. The ideal situation is that somebody is being seen by their primary care provider and that primary care provider is then referring them over to the BHC—even on the same day, walking that patient over to see the BHC. The BHCs typically are encouraged to have their schedules set up in a way that allows them to see scheduled appointments, as well as walk-in appointments. Part of this arrangement is meant to provide folks access to behavioral health consultation as quickly as possible.
DM: The primary end point for this study is the Defense and Veterans Pain Rating Scale (DVPRS), which was originally developed in about 2013 and is now being used broadly throughout the military health system and, increasingly, in the VA and other medical facilities nationwide. This outcome measure is really attendant to the importance of pain-related interference. We, as a field, used to measure pain with the primary end point of pain intensity, but now we're starting to recognize that, at the level of the individual pain sufferer, it's more important to examine how pain is contributing to interference with activities of daily living, recreational activities, work, family, and other domains. This measure does just that, and is now used as the primary clinical outcome for the DHA Pain Management Pathway. The research literature to support use and interpretation of the DVPRS is rapidly growing, so we've also decided to use a measure called the PEG, which is a three-item measure of pain and pain-related interference in activity engagement, general activity and enjoyment. We chose the PEG measurement because it was specifically developed for use in primary care, and it’s a concurrent validity measure to add to the growing research on the psychometric properties of the DVPRS.
We've already shown in our pilot study that you can get a demonstrable and significant improvement in these pain measures during treatment engagement. Now, we're looking at what happens after treatment engagement is over. Once an individual is discharged or discontinues working with the BHC, what happens to the trajectory of these outcomes over time? The trajectory that we noticed in our pilot study was an inflection where patients would improve and then they would worsen after leaving treatment with the BHC, back to where they were at baseline. The goal here is to look at booster versus non-booster augmented brief cognitive behavioral therapy for chronic pain and see if we can flatten that trajectory for the individuals who have the booster contacts. We also hope that we might steepen the curve of improvement with increased engagement because we are providing the booster contacts both during and after treatment, which I think is an important part of this study as well.
JG: We also utilize the Behavioral Health Measure – 20® (BHM-20), which is a standard measure that all BHCs are expected to administer to patients at every appointment within the DOD. The BHM-20 is more of a global functioning measure, particularly looking at mental health functioning and then some other life and social functioning associated with it. In part, we are looking at BHM-20 because it's ubiquitous among BHCs and it's a good, pragmatic aspect of this study. In our pilot study, we didn't see change associated with this measure, so it is unclear how it will play out in the larger study; however, it remains an important measure for us to communicate to our DHA partners about what they may or may not expect to see among patients who are experiencing chronic pain.
DM: Broadly speaking, there are unique obstacles to pain management in an environment like primary care where you have relatively brief contact with patients, but also where the majority of individuals with chronic pain will actually get their care. It's very rare that patients will make it into tertiary or quaternary care and meet with specialists. A lot of the research has shown that there are gaps in primary care education regarding pain management, especially for nonpharmacological interventions. One big step to improving the environment of primary care for chronic pain management is tailor nonpharmacological pain management and training to primary care, which is exactly what the DHA has done. For instance, DHA has brought in opioid education. Of course, a lot of our providers already know about this topic in the context of pain management, but it's helpful to talk a little bit about opioids for pain management and the problems that we've noticed with the opioid epidemic going on right now.
From my work in civilian-based primary care clinics, I’ve learned that a lot of providers are already aware of the presence and availability of nonpharmacological pain management, but they're not aware of the outcomes associated with nonpharmacological interventions. So, it's helpful to talk to them about reasonable expectations for nonpharmacological pain management strategies that can be just as effective as many of the other interventional pain management practices that are being used right now. For instance, having a good provider who can deliver a CBT-based intervention for chronic pain can be just as good, and in some cases, better, than surgeries, radio frequency ablations, injections, and/or courses of medication. If you're able to combine that with some good, solid physical rehabilitation, I think you're really in great shape.
JG: The broader goal of having BHCs in primary care is to provide immediate or quick access to individuals who could provide some of the nonpharmacological types of interventions is key. Another issue is that patients may be referred to specialty clinics sometimes, and, after the referral, communication about the treatments and patient progress (or lack of improvement) provided isn’t communicated back to the primary care provider. This may be more common if it's a mental health clinic referral. Having BHCs housed in primary care gives providers the opportunity to see how patients are responding—not only in the medical notes, but also within the context of their clinic. For those individuals who are not showing improvements, you can more quickly identify them and look at additional or alternative treatment options that are needed when the BHC and the primary care provider are under one roof.
DM: There are many theoretical reasons why a traumatic brain injury, depression, or posttraumatic stress disorder might impact a person's perception of pain, but we're still working our way through a lot of those underlying mechanisms. Pain and pharmacologic pain management can often be a crutch for avoiding symptoms of other conditions, and opioids could certainly be misused to avoid PTSD symptoms. It’s important to address those comorbidities and do it as quickly as you can, but right now, I couldn't really give good advice on whether you need to address PTSD, depression or other conditions before or after you develop a treatment plan for the pain or offer guidance on how those treatment should reasonably be tied together. One of the difficulties we've had as researchers studying chronic pain (and military pain in particular) is figuring out the directionality of the relationships among pain and comorbid conditions. For a long while, I was convinced that PTSD was driving pain, and that if we were able to address the PTSD first, then the pain management should logically follow. I put together a couple of clinical trials looking directly at that hypothesis. What we found, though, is that you can effectively manage chronic pain in the context of PTSD if you do quality nonpharmacological pain management. But treating the PTSD first can be a little bit harder with this particular patient population—and, of course, these aren't definitive outcomes. Much more research is needed, but I do take some solace that if we can manage the pain as well as we possibly can, especially using nonpharmacological strategies, we can help patients improve function, regardless of what the co-occurring comorbidities or conditions are. One of the reasons why these CBT-based and/or mindfulness interventions tend to do well is that they often can address pain and co-occurring conditions at the same time. These nonpharmacological strategies tend to be broad spectrum and so they may be addressing the pain and the co-occurring conditions all at the same time. It is so important to do what we can to ensure the availability of these broad-spectrum nonpharmacological interventions, especially in an environment like primary care where most patients with pain wind up. This is why doing the work that Jeff has put together with this study is so important.
JG: The trial itself has had little adjustments for COVID-19, but the BHCs and their practice have been impacted by it, and we are working to adapt to some degree. For example, a lot of clinics have moved to a mix of seeing patients in person or doing virtual appointments. This practice makes some of the hand-offs to the BHC or other in-house specialists not as smooth as when patients, BHCs, and providers are all in the clinic in person. As a result, the system itself is having to adapt to the number of patients seen for pain and other considerations within the primary care environment. From a trial management perspective, we haven’t had to adapt much since all along we were going to be doing the booster calls by phone and have measures completed electronically. We might've handed out more Fitbits in person, but we always anticipated that we would be mailing some of them out.
DM: Anytime you do research with the military, one of the most important aspects is ensuring that you have good relationships with everyone at all levels and that you have a visibility with the hospital commander, the section commander, the specialty chief, the clinic chief, and the rest of the team. Unfortunately, one of the side effects of the COVID-19 pandemic is that the communication and visibility with our stakeholders at the various sites really started to winnow away—and for good reason. At some places the commanders needed to turn their attention to managing the pandemic at their local site. It's hard to try to step in and say, "But we've got this research program…” when they're just trying to keep people alive. We’ve been fortunate to work with the people and organizations at our sites and in the PMC to continue with the trial. If we were doing it on our own, I think it would've been much more difficult.
DM: Generally speaking, it's rare in pain research to be surrounded by so many people doing such great work. We've gotten a chance to get to know these researchers, work with a number of them, and see everything they're doing. I personally have gotten a chance to work more with investigators like Bob Kerns, Dan Rhon and Stephanie Taylor, who have done a lot of really great work in military and veteran pain research. It's easy to get siloed and to only focus on your own work and to lose perspective, but the PMC gives us a sense of the true breadth of the research. The way the PMC is organized into the different groups and subgroups, as well as the work that leadership has done to give us a direct view into programs like the HEAL Initiative, gives us unique perspectives and connections with folks in the NIH who are working closely with the initiatives.
Additionally, I have been impressed by the amount of support that we got from the PMC. Our trial was directly affected by one component associated with military-specific research, which is a required survey review. It really slowed us down, but the PMC moved mountains for us. Through the PMC, we gained high-level support letters and engagement at the highest levels to problem solve. Eventually, this problem solving became not only a solution to our study, but also a potential future solution for all research studies. I don't think that happens when you do this kind of research alone.
JG: Don described all the ways in which we've been helped. For me, there's also little bit of a group therapy aspect to it. You're with folks who are struggling with similar problems, similar issues, and it's helpful to be in a room with those people, hearing about the ways in which their solutions are working or not working. It’s also inspiring to hear about some of the findings that are coming out and the impact of the research that’s happening even at a preliminary level. In many ways, being a part of the PMC provides the inspiration, motivation, and big-picture view that you hope to get out of going to conferences. I think that sometimes when you're doing research, you can feel siloed and not really sure whether what you're doing is going to be valued by other folks. Having an opportunity to talk about your research with a larger group helps to provide feedback and validation that your work is important, valued, and contributing to the bigger picture.
Working Documents & Other Information
This trial seeks to identify evidence of meaningful outcomes of Brief Cognitive Behavioral Therapy for Chronic Pain (BCBT-CP) interventions within the context of primary care settings, such as decreased opioid medication, fewer emergency room visits for pain care, and greater satisfaction with treatment plans. Co-Principal Investigators: CAPT Jeffrey Goodie, PhD; Don McGeary, PhDRead More