Telephone Cognitive Behavior Therapy for OEF Veterans With Pain

In the VHA, over 50% of OEF/OIF/OND veterans who are seen in primary care settings report
disabling pain symptoms. Although cognitive behavior therapy (CBT) is now commonly employed
within interdisciplinary pain management programs, access to these interventions is often
limited due to the distance from clinical care and disabling impact of pain. In addition,
the dropout rate in studies of face-to-face CBT for chronic pain further detracts from its
impact in pain management. A telephone-delivered version of CBT for chronic pain overcomes
these barriers to access.

Primary Aim: to investigate the effectiveness of telephone CBT in the management of chronic
pain with OEF/OIF/OND veterans enrolled in VA primary care clinics.

Secondary Aim: to determine moderator and mediating factors by which telephone CBT
facilitates pain management and successful adjustment of OEF/OIF/OND veterans to chronic
pain.

Major hypothesis:

Hypothesis 1: Patients who receive telephone CBT will show significantly greater
improvements in coping skills, reduced emotional distress, and increased quality of life
compared with those who participate in telephone pain education (EDU).

Hypothesis 2: The dropout rate for both of the telephone interventions in this study will
be significantly lower than the attrition rate found in previous studies of face-to-face CBT
for chronic pain.

Secondary hypothesis:

Hypothesis 3: An increase in use of coping skills will be positively associated with
treatment outcome measures reflecting improved adjustment to chronic pain.

Hypothesis 4: A decrease in catastrophizing will be positively associated with treatment
outcome measures reflecting improved adjustment to chronic pain.

To accomplish these aims, we will conduct a randomized clinical trial comparing
telephone-delivered cognitive behavior therapy and pain education control. A total of 150
OEF/OIF/OND veterans with chronic pain will be enrolled in the study and randomized into one
of two treatment conditions. The study sample will be recruited from primary care clinics
at the San Francisco VA Medical Center and affiliated VA community-based outpatient clinics
(CBOCs) in downtown San Francisco, Eureka, San Bruno, Santa Rosa, and Ukiah. Recruitment
will target OEF/OIF/OND veterans with pain disorders that involve muscle strain and
inflammation, trauma to nerves, and/or central nervous system dysfunction. Both
interventions will be delivered by telephone and consist of 12 sessions scheduled over a
20-week period. Pain management outcomes will be measured at 10 weeks (mid-treatment), 20
weeks (post-treatment), 32 weeks (3-month follow-up), and 46 weeks (6-month follow-up). The
sample size will provide greater than 80% power at a two-tailed alpha of 0.05. The study
hypothesis, assessment methodology, and intervention procedures are based on the
cognitive-behavioral model of chronic pain.

Inclusion Criteria:

To be eligible to participate in this study, potential subjects must have:

- access to a telephone

- documented pain for at least the past year

- a pain disorder involving muscle strain and inflammation, trauma to nerves, or
central nervous system dysfunction

- pain condition must be stable

- must have no clear indication for specific medical/surgical intervention.

Exclusion Criteria:

Patients will be excluded who are:

- acutely psychotic

- cognitively impaired

- show significant suicidal risk (history of multiple suicide attempts or actively
suicidal)

- currently abusing alcohol or other drugs, including prescribed opioid pain
medications

- patients will also be excluded who have an unstable medical condition and clear
indication for specific medical/surgical intervention in the near future.