Engaging Veterans Seeking Service-Connection Payments in Pain Treatment

In 2015 alone, 97,223 new Veterans under age 35 began receiving compensation for injuries
related to their military service. In total, there are 559,999 post-9/11 Veterans being
compensated for back or neck conditions, and a partially overlapping 596,250 for limitation
of flexion in joints. Veterans seeking compensation for musculoskeletal conditions often
develop chronic pain and are at high risk for substance misuse. Early intervention is needed
to arrest worsening pain and risky substance use, particularly among post-9/11 Veterans for
whom engagement in non-pharmacological pain treatment has the potential to improve their
overall quality of life and spare them the complications of opioid treatments. The
service-connection application is an ideal point-of-contact for initiating early intervention
treatments for these at-risk Veterans. The Investigators propose to test the effectiveness
and cost-effectiveness of Screening, Brief Intervention and Referral to Treatment for Pain
Management (SBIRT-PM), designed to reduce pain and risky substance use. In brief, the
counselor explains that treating both physical and psychological aspects of pain leads to the
best outcomes, outlines what VA (and non-VA if preferred) services are available to Veterans,
explains that substances are sometimes used for pain relief, and segues into traditional
SBIRT. SBIRT-PM's efficacy is supported by a completed clinical trial of 101 Veterans
applying for service-connection for MSD, and by studies showing the efficacy of SBIRT for
people with risky substance use and of Motivational Interviewing for engagement in
non-pharmacological pain care. The study will involve a two-year period to arrange for
clinicians at a single "hub" site to counsel Veterans throughout New England by phone with
SBIRT-PM, and a four-year period to conduct the clinical trial and disseminate its findings.
During the two-years of preparation for the clinical trial, the team will prepare SBIRT-PM
for implementation by establishing communication (Relational Coordination is the theoretical
framework) between the "hub" where the SBIRT-PM clinician is sited and the "spoke" sites,
establishing study-related procedures, and piloting the intervention at each of the eight VA
medical centers in New England. For the full clinical trial, investigators will randomize
1200 Veterans applying for compensation related to MSD to either SBIRT-PM or Usual Care (UC)
across eight VA medical centers in New England. Outcome assessment by phone will occur at 12
and 36-week follow-ups, and will be corroborated with other sources of information ---the
electronic health record and toxicology testing of nail clippings. Investigators hypothesize
that, compared to Usual Care, SBIRT-PM will be more effective and cost-effective in improving
Veterans' pain and substance use. Investigators further hypothesize that a mediator of these
improvements will be use of non-pharmacological services, as extracted from VA records from
structured data fields and from narrative text in the medical record using an innovative
natural language processing algorithm. Screening and referral to treatment at
service-connection examinations can transform a widely-used point of entry to VA into a
health-promoting encounter.

Inclusion Criteria:

- Post-9/11 Veteran applying for MSD-related compensation, as ascertained from filed
claim,

- Reports pain ≥4 on the pain Numerical Rating Scale (threshold for moderately severe
pain);

- Availability of a landline or cellular telephone for SBIRT-PM.

Exclusion Criteria:

- Reports inability to participate during the study enrollment call

- Received three or more non-pharmacological pain treatment modalities (as previously
categorized within the last 12 weeks from VA.