Targeting Chronic Pain in Military Primary Care Settings Using Internal Behavioral Health Consultants


Enhance delivery of chronic pain care in U.S. military primary care clinics by developing a manual and training program for providers in a drug-free pain management therapy that helps to reduce the use of opioid medications; evaluate the program in a pragmatic clinical trial involving patients with chronic pain.

Chronic pain is one of the most common and disabling conditions in U.S. military service members and their beneficiaries, and it is the leading cause of discharge from military service. As in the civilian population, addictive opioid medications have become the most common treatment for chronic pain in service members. But heavy reliance on those drugs has led to a national opioid crisis in which tens of thousands of Americans annually die from overdoses, according to the Centers for Disease Control and Prevention.

STRONG STAR part of national response

In response to this crisis, the National Institutes of Health and the Departments of Defense (DoD) and Veterans Affairs (VA) jointly established a national Pain Management Collaboratory. This collaboratory includes 11 individually funded pragmatic clinical trials with a focus on drug-free approaches to pain management in health care organizations that serve military personnel and veterans. Pragmatic trials take place in real-world settings with typical patients and produce results readily applicable in routine medical practice.

One of the Pain Management Collaboratory trials is a STRONG STAR-affiliated study designed to support the military’s own efforts to reduce the use of opioids for managing pain, while providing alternatives so that patients whose prescriptions are discontinued do not turn to civilian providers or street drugs.

This two-phase pragmatic trial is led by Principal Investigators (PIs) Donald McGeary, PhD, of The University of Texas Health Science Center at San Antonio and CAPT Jeffrey Goodie, PhD, of the Uniformed Services University of the Health Sciences. The study will offer the first formal pain management training specifically targeting the internal behavioral health consultants (IBHCs) already at primary care clinics throughout the U.S. Military Health System (MHS). IBHCs, who manage mental health and health behavior issues among primary care patients, previously received no formal training in drug-free pain management.

Managing pain without opioids

Most military personnel and family members with chronic pain receive treatment through primary care services. To enhance delivery of chronic pain management in primary care, the U.S. Defense Health Agency (DHA) has teamed up with the VA to establish a “stepped care” model of pain management tailored to the needs of the MHS. Stepped care delivers the least resource-intensive treatment before “stepping up” to the use of specialists.

This stepped care model, called the “Pain Pathway,” will guide assessment, treatment, and referral of chronic pain patients in MHS primary care clinics. Pain Pathway emphasizes drug-free interventions to replace opioids as the No. 1 way to manage pain. It includes provider training and education, establishment of clinic “Pain Champions” to optimize pain management services, and use of the internal behavioral health consultants.

How the study will work, expected benefits

The research team led by Drs. McGeary and Goodie will work directly with the DHA to develop a brief manual for treatment based on the VA’s Brief Cognitive Behavioral Therapy for Chronic Pain. The intervention includes providing information about chronic pain, relaxation, and stress management; cognitive and behavioral therapies designed to improve pain coping and increase physical activity; strategies for activity pacing and functional activation; and specialized modules for addressing pain-related concerns such as stigma, depression, and insomnia.

Then, the team will establish a program for training IBHCs in this non-pharmacological pain management intervention and test its effectiveness among primary care patients with chronic musculoskeletal pain.

The first phase of the program included the development of materials for training and treatment, assessment of the work products by key stakeholders (DHA leadership, IBHCs, primary care clinicians, and patients), and a pilot test of the IBHC intervention with 42 patients at Fort Hood (since renamed Fort Cavazos), TX.

The second phase includes a study of the intervention with IBHCs stationed at three military treatment facilities. The investigators plan to recruit about 700 patients with chronic pain at these sites.

If successful, this program will increase the number of military primary care clinics with staff trained to deliver a medication-free pain management program that improves quality of life for service members and dependents, prevents medical discharges, and reduces costs for healthcare, disability, and other expenses.

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