Brief Cognitive Behavioral Therapy for Chronic Pain

We will recruit 30 Veterans from the primary care clinics located at the Buffalo Veterans Affairs medical center in Buffalo, New York. Thirty eligible participants will be randomized in a 1:1 ratio into either (1) Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP) plus treatment as usual (TAU) or (2) TAU only. We will engage in recruitment during the second quarter of Year 1 through the end of the first quarter of Year 2. We aim to recruit and enroll 7-8 participants per quarter during that time frame. Post-treatment follow-up will be conducted at eight weeks and at 12 weeks. Two recruitment methods will be used. Veterans with chronic musculoskeletal pain who self-report functional impairment will be referred by their primary care team, in response to a recruitment flyer posted in primary care, or by contacting the principal investigator or study staff directly after hearing of the study by word of mouth or other sources. This approach will be supplemented by a case-finding procedure in which study staff review electronic medical record data to identify potential patients, who will be subsequently contacted by letter and screened by telephone. Following telephone screening, potentially eligible participants will complete a baseline assessment to assess pain and related characteristics as well as remaining exclusion criteria. Those passing baseline measures will be randomized to (1) Brief CBT-CP plus TAU or (2) TAU only. Assignment to Brief CBT-CP will be stratified based on degree of pain interference.

Brief CBT-CP is a manualized protocol that includes six, 30-minute sessions over the course of 6 weeks. Brief CBT-CP session outlines and patient handouts are included in the appendix. Session one focuses on foundational pain education and the development of treatment goals. Session two emphasizes balanced engagement in physical activity and pleasurable events. Session three emphasizes skills training for easily implemented relaxation techniques. Sessions four and five focus on recognizing and modifying unhelpful thoughts that negatively impact pain. Session six focuses on relapse prevention and independent implementation of CBT-CP skills following treatment. Brief CBT-CP will be delivered by a masters-level interventionist either at the medical center or by telephone depending on the preference of the participant.

Participants assigned to TAU only will receive standard medical care from their primary care provider including pain medications, brief advice (e.g., use of relative rest, application of heat or ice, other self-care strategies), or referral to pain-related adjunctive interventions (e.g., physical therapy), as indicated. Participants in TAU only will not receive behavioral intervention from the primary care clinic behavioral health provider.

We will conduct brief interviews with up to 24 purposefully selected participants (i.e., 12 providers and 12 patients). The provider group will include 6 primary care providers and 6 behavioral health providers I providers who staff Veterans Affairs primary care clinics. Interview items are based on implementation constructs relevant for early stage intervention development: acceptability (or agreeableness and satisfaction with treatment components), appropriateness (or perceived fit/compatibility of the intervention), and feasibility (or whether the intervention is suitable for use.) Up to 12 patients who were randomized to Brief CBT-CP will be asked to complete a 30-minute interviews (i.e., telephone or face-to-face, depending on participant preference) following their 12-week assessment (as described in the consent procedures prior to the trial). We will include participants who completed all study procedures but will also attempt to include those who discontinued Brief CBT-CP.

Inclusion criteria

• A diagnosis of musculoskeletal pain of three months
• Pain-related functional impairment
• If currently prescribed pain or psychiatric medicine, a stable dose in the last three months (other than over-the-counter medicines)
• Conversant in English
• Established history of Veterans Affairs primary care utilization (i.e., at least one primary care visit in the past year)

Exclusion criteria

• Current engagement in psychotherapy or behavioral intervention provided by behavioral medicine services, specialty mental health, or Primary Care Mental Health Integration services for any indication. Note that medication management through these services is not excluded.
• Receiving medical treatments (e.g., surgery, injections) known to impact pain-related outcomes
• Endorsement of imminent suicide risk
• Current substance use problems (i.e., alcohol, opioids, benzodiazepines, or other drugs)
• Unstable psychiatric status (e.g., active psychosis, current mania)
• Diagnosed with major or minor neurocognitive disorder
• Unwilling to have treatment sessions audio recorded