Steve Martino (SM):  We are looking at how to support the case managers’ use of SBIRT-PM to engage veterans in pain care AND to address problems of addiction. We have two different strategies. One is a training-only approach, or “training as usual,” where I provided M2VA teams eight hours of virtual training in the use of motivational interviewing to address pain and addiction. In those trainings, we also spent time helping the case managers understand the pain care system in the VA so that they can speak with clarity about pain care when they’re talking to veterans who might need those services. The training also includes a simulation experience, wherein we hired veterans with lived experiences of pain to act in different scenarios so that case managers could practice using motivational interviewing and get feedback about how well they did. The second strategy provides the same training and adds to it extra support to address organizational factors that might help or hinder the case managers’ use of motivational interviewing. This extra support is referred to implementation facilitation.

Marc Rosen (MR): A shorthand for this trial would be that in one group, you just train the case managers in motivational interviewing and pain care, and you say, “go.” In the other group, you say, “Well, it’s not just up to the case managers, it’s up to connecting them to the rest of the hospital.” The second approach involves engaging the rest of the health care system with the hope that if you do that, they’ll make better referrals because they’ll know the groups to which they’re referring veterans. We have trained the M2VA case managers at 14 VAs around the country, and randomized the sites, with some getting the “trained and go” approach and some getting the “trained and connected” approach. We currently are recruiting 14 more sites to participate in the trial. In total, 14 sites will receive training only and 14 sites will receive training plus implementation facilitation.

SM: This is a broad-based, system-level support strategy that builds relationships with M2VA case management teams and key partners that are important for the delivery of pain care within the medical centers. The M2VA teams become more integrated with those key partners, which helps to problem solve different types of issues that may arise and the strategy also provides the M2VA teams with ongoing support and consultation. For example, case managers learn more about pain and comorbidities associated with pain, like opioid use disorder and cannabis use. We also provide M2VA case managers with detailed feedback about their simulated role-playing sessions through an AI motivational interviewing integrity rating system. The AI system processes the recorded sessions. The information from the AI system is provided to case managers, giving them detailed information about how well they are using motivational interviewing during the simulated patient encounters. It’s a multifaceted series of supports that are being provided on top of the training to help motivational interviewing become part of how they provide case management to veterans who have pain and problems of addiction.


Said differently, we’re trying to make motivational interviewing a way of case managing, not, “here’s one more thing to do.” It’s a style of talking with people in a way that might most effectively prepare them to make changes that can improve their health. Most veterans have many things happening at the same time. We’re targeting pain and then addiction, but, invariably, our conversations have gone to other types of issues, too, like mental health and psychosocial concerns.


Our implementation facilitation is not stagnant; it grows and shifts at each site. With the implementation facilitation, we’re trying to see if all the extra support improves the degree to which the case managers reach veterans who have chronic pain or addiction with motivational interviewing and if that the practice is adopted consistently and implemented well.

SM: Our main partner for this study is the Post-9/11 Military2VA (M2VA) Case Management program, which helps new veterans transitioning from active duty engage in and navigate the VA health care system. Every VA has at least one M2VA case manager, and some sites have large teams. We partnered with them in large part because the work that the case managers do was consistent with what our intervention tried to do: motivate veterans to engage in pain care. This was a great opportunity to reach veterans as they’re coming out of the military and to intervene early in the process to get them engaged in VA treatment sooner rather than later. We have formed a fantastic partnership with the national M2VA leadership. Without them, we could not do this work.

SM:  Half of the individuals who leave the military will ultimately be found to have had a musculoskeletal condition that was caused or worsened by their military service. Whether the case managers recognize it or not, they are seeing a large number of veterans with chronic pain and, for the most part, the M2VA teams were not trained to address these veterans’ need for pain treatments. The veterans with pain who are coming into the VA have to be connected to the providers who have the responsibility to care for them, and the M2VA helps make this connection. In our formative evaluation, we learned that often the M2VA case management teams and pain care providers didn’t know each other. Organizational support is needed to bridge this gap. If M2VA staff are learning to connect Veterans to the pain care system, the learning can be more effective if M2VA staff have relationships with the pain care group. Part of the aim of implementation facilitation in this trial is to help build a working relationship between M2VA and pain care teams.


MR:  The 20,000-foot view is that too many veterans are on too many opioids. Getting them to non-opioid pain care requires that the people who make those referrals–the M2VA case managers—know what non-opioid pain care is, know who the providers are, and are able to effectively get the veterans to those providers.

Part of this training is explaining to the case managers what the available pain treatments are. A lot of veterans with chronic pain don’t sleep well and get depressed. People who are in enough pain for a long enough time get discouraged; they become less active, and they become depressed. If you’re a case manager who hasn’t had a lot of training, it’s not obvious that referring someone in chronic pain to sleep treatment or depression treatment is pain treatment. But it is. People who have gotten enough rest and have gotten treatment for depression are better able to cope with their pain better and report less pain.

SM: The pain care system in the VA continues to be complex. There was an influx of resources that were being built up during our first trial: supports like Whole Health, PMOP [Pain Management, Opioid Safety and Prescription Drug Monitoring Program] coordinators and Pain Care Points of Contact, as well as more care options such as chiropractic care and acupuncture. The pain care pathway for directing veterans with pain care needs wasn’t clear; if there is no one at the VA to guide these veterans, it can be discouraging, and veterans won’t get what they need. One thing we’ve learned is that an intervention like the one we’ve developed–and have found to be at least somewhat effective–is needed to help Veterans understand available pain care options and motivate them to engage in preferred services at their VA.

MR: In the first project, we took people who were applying for service connection for a disability. They could be reapplying. They could be older. From our experience, it was harder to steer someone who’s had chronic pain for ten years and has been in the VA system for a while; they have ideas about what works for them and what doesn’t. With the M2VA project, we decided that the best place to intervene was with M2VA because they work with veterans new to the VA. You’re getting younger people who don’t have as firmly developed ideas about what pain care is and about what works for them. By getting them into pain care early, you can help them before the pain becomes chronic and opioids are prescribed.

In the first study, we worked with therapists, who were not VA employees, to deliver the counseling. That has its pros and cons. One of the cons was that the therapists were not VA insiders. They didn’t know the VA that well. Finding M2VA—a group whose mission is to engage new veterans and steer them to the appropriate treatments—gave us a group of case managers who know the VA. A lot of the M2VA case managers are veterans who have had chronic pain , and they work their experience into their conversations with new Veterans. When you talk to M2VA staff about a pain care issue, they often have lots of anecdotes and it’s applicable to the people they work with. They’ve just been terrific partners.

SM: The PMC has emphasized the importance of building relationships with key partners in whatever you do. I think a big part of the PMC is networking and making sure that we’re thinking about all the various partners who will be necessary to be successful in implementing our trial and ultimately disseminating it.

While the idea for the M2VA did not come from the PMC, I would say the spirit of it maybe was supported by the PMC. In a way, it gave us the wind in our sails. They also have provided very specific support. The Partner Engagement work group, for example, helped lead us to the CORE Veterans Engagement Panel—a veteran engagement group—that really helped us shape the way we did our simulations. It was extremely helpful.

MR:We found that the people who were offered the motivational interviewing intervention overwhelmingly took it, which is not obvious, given that these people were not seeking treatment; they were seeking service connections. So, one finding is just that people who were seeking service connection were amenable to treatment. As you’d expect, the people who got the motivational interviewing-based treatment were significantly more motivated to engage in pain care. That motivation appeared to translate into them being significantly more likely to attend VA sponsored outpatient pain treatments. Presumably, from attending those treatments, they had significantly less pain 36 weeks after they started the study.

SM:We pondered: how did the trial do what it did? Why did it have these effects? Part of it might be that, through the counseling, we were successful in getting veterans more motivated to engage in care—despite the trial running during the pandemic. Positive impacts occurred, even with all the dramatic effects on the health care system, including, for a time, limited access to pain care. So, while the effects that we achieved were small, the fact that they occurred during pandemic-induced institutional disruption is important. That’s a pragmatic trial, right? Conduct the work in the real world. Well, this is as real as real can be, and still we were able, with a very brief intervention, to find a statistically significant benefit from the intervention during a time of upheaval.

MR: The intervention cost about $300 and the extra VA care cost about $1400 and there was a reduction in pain for participants. From a societal perspective, participants who received the intervention also were able to work and spend their leisure time more productively, and the financial value of that is substantial. For a total of $1400 in spending, the benefits to workplace productivity and improved general activity were about $3,700.

MR: It’s fun to see people yearly, catch up on their projects, and see their projects develop over time. These are complicated projects; it takes a while to understand them, and you need to hear about them more than once to start to make connections. It’s really been extraordinary to have this kind of support over years and years on a consistent mission. The projects get better, and more are getting implemented.


SM: Beyond everything that Marc has said, I like the way the investigators have become more open to implementation science, which is one of my research interests. When we came on to the PMC, it was a more conservative, pragmatic trial perspective; now I feel like the Collaboratory is more specifically embracing implementation science as part of pragmatic work. I like this evolution of the PMC.