Telehealth CBT to increase engagement in pain treatment among Veterans using prescription opioids

Veterans Affairs, United States Department Of, Canandaigua NY

Investigators

Abstract

Background: There are striking disparities in the opioid crisis and growing evidence of racial disparities related to chronic pain prevalence, management, and pain outcomes (e.g., higher opioid oversdose deaths), especially for African American (AA) patients. Racism (e.g. race-related stress [RSS]) is a key social determinant of health negatively impacting assessment and treatment of pain, and treatment-seeking behaviors among AA. To reduce disparities, it is imperative to address treatment-seeking behaviors that can help facilitate engagement in treatment for pain among AA in culturally sensitive way. Clinical Practice Guidelines for opioid prescribing and pain management recommend using non-pharmacological approaches as first-line treatments. Psychosocial interventions (e.g., cognitive-behavioral therapy) have strong evidence supporting their ability to improve pain outcomes. Inherent to the CBT approach are culturally-sensitive techniques (e.g., individualism, non-judgement, collaboration, empowerment) that are particularly advantageous when working with AA. Significance/Impact: Without a concerted effort to attend to AA group specific-needs–in a culturally-sensitive way that can affect beliefs that impede engagement in treatment–AA Veterans who may benefit from the treatment, will not receive it. This can result in continued risk for negative consequences associated with long- term opioid therapy and a perpepuation of racial disparities. Cognitive-Behavioral Therapy for Treatment Seeking (CBT-TS) is an evidence-based intervention that directly intervenes on beliefs that act as barriers to treatment initiation and retention. As a CBT approach, CBT-TS lends itself well to working with culturally diverse patients, particularly AA patients. By intervening on these beliefs, in a culturally-sensitive way, this study has the potential to improve engagement in psychosocial pain interventions and other non-pharmacological pain treatments, which will improve pain-related outcomes and increase treatment engagement among AA. This study addresses VHA/VA Veteran care priorities including opioid use, pain management, and access and directly addresses priorities of the HSR&D Targeted Solicitation for Resarch Supplements to Promote Diversity. Specific Aims: The primary objective of the proposed project is to examine the efficacy of, and mechanisms of action in CBT-TS to identify factors that facilitate the initiation of psychosocial pain treatment among AAV using opioid analgesics for chronic pain. The specific aims are to: examine treatment efficacy (treatment initiation) for CBT-TS among AAV receiving opioid analgesics for chronic pain (Aim 1); identify mechanisms of action in CBT- TS that increase treatment initiation among AAV receiving opioid analgesics for chronic pain (Aim 2); examine the effects of racism (experiences of racial discrimination, race-related stress) on treatment initiation, retention and completion for AAV who receive psychosocial treatment for chronic pain management (Exploratory). Methodology: Participants (N = 300) will be randomized to either the CBT-TS condition or an education control condition. Approximately 25% (N = 76) of this sample will be AA and used in analyses. AAarticipants in both conditions will complete assessments on pain, treatment engagement (including questions specific to culturally sensitve mechanicsms), race-related stress and opioid use at baseline, and 1-, 3-, and 6-months post-treatment to assess primary, secondary, and exploratory outcomes. Next Steps: Results from this study will provide critical information on increasing engagement of AA psychosocial interventions for pain and provide data on the impact of race-related stress on treatment seeking behaviors and engagement. This study will provide critical pilot data on mechanisms of action that are particulary salient for AA treatment engagment. This study is the first-step toward developing a more culturally sensitive approach to treatment of chronic pain for AA Veterans. Next steps involve a trial utilizing data from this project to prepare an application to evaluate the feasibility, acceptability, and safety of a modified version of CBT-TS and later a larger randomized clinical trial to examine the efficacy of the adapted treatment.