Pain Management and PACT
Overview

• Chronic pain in primary care

• Integrating pain care management with 

PCMHI for PACT approach

• Research results: An intervention to help 

manage chronic pain in primary care

– Description

– Preliminary results

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Poll Question #1

• What is your primary role in VA? 

– student, trainee, or fellow

– clinician

– researcher 

– manager or policy-maker 

– Other 
Poll Question #2

• Which best describes your research 

experience?

– have not done research

– have collaborated on research

– have conducted research myself

– have applied for research funding

– have led a funded research grant
Background: Chronic Pain

• Pain that persists for >3-6 months after 

disease process or injury that has healed

• Associated with significant health care 

expenditures, disability, lost productivity

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Chronic Pain

• Common among veterans

• Usually treated in primary care

• One of the top complaints that bring patients 

to their primary care providers 

– 40% of all symptom-related outpatient visits

– 95% of pain is managed in primary care
Chronic Pain

• Prevalence in the VA = 50% of veterans in PC settings report 

disabling pain symptoms

• Highly comorbid with psychiatric conditions (dep, anx) 

• Medications for pain limited in effectiveness for some 

patients 

• A significant challenge for PCP’s; consumes time and 

resources

• Intervening at early stages may help reduce long-term 

disability, referral to specialty care (e.g., surgical clinics)
The Challenge of PC Providers in 

Helping Veterans with Pain

• Providers’ comfort level in managing chronic 

pain varies

• Time limitations

• Concerns about prescription medications 

(e.g., opioids)

• Provider internal pressure to “do something”

• Unrealistic patient expectations

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Depression and Chronic Pain

• Additional clinical burden for patients with both 

depression and chronic pain

• 2006 study: among patients in primary care 

clinics 

– Patients with MDD 66% with chronic pain

– Patients without MDD 43% with chronic pain

– Patients with both MDD and chronic pain

• poorer quality of life 

• anxiety

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Depression and Chronic Pain

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Depression and Chronic Pain

• Treating depression for patients with 

both pain and depression linked with:

–decreased pain

–improved functional status

–Improved quality of life 

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BIOPSYCHOSOCIAL MODEL OF PAIN

 

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Social Factors

Psychological 

Factors

Biological Factors

Behavioral 

Factors
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Chronic Pain

• Complex response to a number of factors:

– Physiological/Biological

• Intensity of tissue damage

• Biologically-based individual differences in pain threshold and 

sensitivity

• Site of injury or source of painful stimuli

– Psychological 

• Emotional status

• Attentional effects

• Beliefs and expectations

• Self-efficacy 

• Pain experiences

• General physical health

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Chronic Pain Management

• Guidelines for pain management

– Include biopsychosocial model 

• Evidence that exercise and encouraging 

resumption of normal activities reduces 

activity limitations due to pain

• Address fear-avoidance – belief that activity 

and movement will increase risk for re-injury

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CBT for Chronic Pain

• Treatment outcome studies demonstrate 

effectiveness

• Can be a key component of interdisciplinary 

pain management programs 

• Educational interventions have also been 

shown to be helpful

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Barriers to CBT for Chronic Pain

• Travel distance

• Schedules that preclude appointments

• Illness and disability related to chronic pain

• Effective use of resources

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Integrated Model of Pain care

• Level 1: primary responsibility with PC

• Level 2: patient education, rehabilitation 

model

– Discussion of pain management model

– Personalized exercise plan

– Practice of self-regulatory pain strategies

• Level 3: Comprehensive pain management

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Stepped-Care Approach

• Sequenced interventions

• Target resources

• Guided by patient outcome

• Step 1:

– Incorporate collaborative care with behavioral 

health and target pain management treatment 

– Population-based: targeting the greatest volume 

of patients reporting pain

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The Behavioral Health Lab (BHL)

• PCMHI at the PVAMC

• Provides behavioral health assessment and triage to 

patients in primary care

• Provides brief behavioral health treatment for 

patients in primary care

– Depression, anxiety, alcohol misuse

• Robust evidence base for depression care 

management, alcohol brief interventions (alcohol 

misuse), and referral management 
PC-MHI and the Patient Aligned Care Team (PACT)

• “Behavioral health and primary care are inseparable, and any 

attempts to separate the two lead to suboptimal care.” (PatientCentered Primary Care Collaborative, 2010)

• Particularly relevant to two joint principles of the medical 

home:

– Whole Person Orientation

– Coordinated/Integrated Care

• “Mental health as particularly important to the context of the 

whole person” (Robert Graham Center, 2007)

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BHL Clinical Process

Patient Identification

Screening / Clinical Assessment / Casefinding

Initial 

Assessment 

Consultation

Or 

Referral Mgt

Treatment 

Recommendations

Brief Treatment 

& 

Care 

Management

No treatment 

& 

Refusal of care

Patient 

Education 

and Promote 

Self-Care

Watchful waiting

& 

Brief Interventions 

Specialty Care Evidence based 

protocols

Prevention / Health 

Promotion

BHL software 

– provides the 

platform
Chronic Pain Identified by BHL Consult

• Survey of 606 patients referred to the 

BHL

– over 80% of patients reported pain that interfered 

with their daily activities

• Pilot study

– Development of brief intervention for level 1 of 

stepped care
Pilot Study for Pain Care

• Based on interventions that have been 

effective in previous studies 

• Developed to be delivered by a care manager 

(nurse, psychologist, social worker)

• Developed to be conducted by telephone or in 

person for greater access

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Behavioral Health Laboratory: Components

A clinical management program focused on:

• Identification 

• Assessment and triage to appropriate level of care

• Care Management / Brief treatment/ Health Promotion 

and Disease Prevention

• Using specialty care and facilitating engagement

• Tracking: Referral Management
Initial Triage

• All patients entering the program complete standard baseline

• Completed via phone or in person (patient preference)

• Includes array of behavioral health symptoms and substance 

use and overall functioning

• Helps determine next step in treatment

• Completion rate of 80%

• BHL Software output: clinical report, patient letter
Initial Triage Assessment

• Demographics

• Current MH care 

• Financial status

• Social support

• Blessed Orientation-Memory-Concentration (>55 yrs or head injury)

• Mini International Neuropsychiatric Interview (psychosis, mania, GAD, panic)

• Depression assessment: PHQ-9 

• PTSD Checklist (PCL-c)

• Anxiety assessment: GAD-7 (optional)

• Brief Pain Inventory Interference scale 

• Current Psychotropic/Pain medications

• 5-item Paykel scale for suicidal ideation

• Alcohol use (7 day follow-back)

• Illicit substance use

• Depression history

• Work Limitations questionnaire (optional)

• SF-12 (optional)
Behavioral Health Lab Interventions

• Stepped care approach

• Longitudinal but brief treatments

• Promote patient self-management

• Collaborate with PCP

• Pharmacological support

• Measurement based
Measurement Based: BHL Software

• Built in interview for tracking follow-up contacts for care 

management/brief treatment

• 6 optional domains:

– Depression: PHQ-9 

– Anxiety: GAD-7 

– PTSD: PCL-c 

– Pain: BPI for pain interference

– Alcohol: 7-day time line follow-back 

– Referral Management: to track engagement in 

specialty care
BHL Provider: the Glue

Primary Care 

Clinician 

Mental Health 

Supervisor

 

BHL provider Patient 
Patient Tracking– Measurement based care
Helping Veterans Manage Chronic Pain

• Center for Evaluation of PACT (CEPACT) funded

• Investigators: Intervention Team:

– Amy Helstrom, PhD. Kristyna Bedek, PsyD

– Johanna Klaus, Ph.D. Sherry Cocozza, RN

– David Oslin, M.D. Lisa Dragani, RN

• Research Team: Nisha Nayak, Ph.D.

– Natacha Jacques, MA

– Melissa Correa, BA 

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Pain Care Management (PCM)

Project Objective: To test the effectiveness and sustainability of an 

integrated primary care based program for veterans with chronic pain 

designed strengthen pain management skills and improve quality of life. 

• Goals

– Reduce and/or prevent pain-related disability

– Improve affect associated behavioral health disorders (e.g., depression, 

anxiety)

– Enhance overall quality of life for the veteran

– Reduce primary care providers’ time.

 

• Built on empirical support for Depression Care Management, Alcohol Care 

Management, Specialty Care Referral

 
Main Research Questions

• Does the addition of PCM to existing PCMHI 

program lead to better pain outcomes than 

usual care?

• To what extent does the intervention lead to 

improvement on quality of life?

• To what extent does the intervention improve 

depression and anxiety outcomes?

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Study Design

• Randomized treatment outcome study

–Treatment (Pain Care Management: 

PCM) 

–Usual care (depression or anxiety care 

management) 
Measures

• Outcomes: quality of life, pain interference, 

pain level, pain severity, depression, anxiety

• Predictors: Fear-avoidance, pain 

catastrophizing, coping style

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Usual Care

• Support

• Psychoeducation

• Behavioral activation

• Consultation with psychiatry

• Collaboration with PC

• Motivational enhancement approach

• Referral to specialty care when necessary

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PCM

• Usual care plus:

– Psychoeducation about pain

– Practice self-monitoring of pain levels

– SMART goal-setting and problem solving

– Relaxation

• Deep breathing

• Guided imagery

– Pacing

– Learning to recognize and manage pain flare-ups
EDUCATION: GATE CONTROL THEORY

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Situation/ 

Behavior/ 

Physical State

Thoughts

Emotions 

Pain “Volume” Controls

Gate

(open/ 

closed)

Pain Center

Emotion Center

Thought Center

Site of Injury
PCM also included:

• Workbook sent to the home

• CD with relaxation strategies

• Role of relaxation in managing chronic pain

• Diaphragmatic breathing

• Borrows from behaviorally-based 

interventions that have been demonstrated to 

be effective (e.g., Dobscha, Kerns, Otis, 

Kroenke) 

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Both conditions included

• Use of BHL software

• Referral to specialty care

• Consultation with psychiatrist

• Collaboration with PCP

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Recruitment and Eligibility

• BHL referral

• Inclusion criteria

– Pain

• Severity > 5 out of 10 OR

• Interference > 5 out of 10

– Exclusion criteria

• Need for specialty mental health care

• Engaged in specialty pain management (did not 

exclude patients taking opioids, other pain 

medications) 

• Problems with cognition
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PCM Study Procedures

Patient Identification from Primary Care for Depression, 

Anxiety Screening / Clinical Assessment

BHL Initial 

Assessment Patients who meet 

inclusion criteria with 

interest in study

No treatment 

& 

Refusal of care

Patients who do not 

meet criteria, with 

exclusion criteria, or not 

interested 

Informed Consent Administered

Participants Randomized to 

Treatment

Control 

Condition: 

Begin Dep, 

Anx Care 

Management 

(12 weeks)

Treatment 

Condition: 

Pain Care 

Management 

(12 weeks)

Assessment (both 

groups):

•Baseline

•During Treatment

 0, 2, 4, 6, 9, 12 weeks

•Maintenance/Follow-Up

 16,20, 24 weeks

Patients who meet 

inclusion criteria but 

not interested in 

study: BHL Pain Care 

Management
Participants 

• 376 veterans referred and preliminarily 

eligible

– 216 declined or were excluded based on 

additional chart review, inability to be contacted

• 160 veterans enrolled

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Sample Characteristics: Pain

• What has been your worst pain in the last 24 hours? (0-10)

– 84% 6 or more

– 21% 10

• What has your avg. pain severity been in the last 24 hours (>5 

on 0-10)?

– 96% 

• What has been your avg interference due to pain in the last 24 

hours (>5+ on 0-10 scale)?

– 90%

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Put an X on the area that hurts the 

most

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x 

X X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X X 

X X X 

X 

X 

X 

X 

X 
Baseline Pain Management Techniques

• Heating pads

• Stretching 

• Exercise

• Medication 

• Shower

• Physical therapy

• Ice

• Quiet

• Massage

• Rest

• Activity

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What Exacerbates My Pain?

• Activity

• Lifting

• Weather

• Not enough activity

• Standing

• Sitting

• Walking too long

• Stress, worry

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Follow-Up Rates

• Average # Sessions

– PCM 5 

– UC 3 

• Overall, 38% completed 3 or fewer sessions

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Participant Demographics

• Average age 54 (22-87 years)

• 57% African-American

• 37% White

• 85% male

• 46% married/partnered

• 23% employed

• 52% financial situation - just enough to get 

along

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Participant Characteristics: 

Psychological Variables 

PHQ-9 Depression Score, % 

Moderately-Severe & Severe 49.5 

Moderate 27

AUDIT-C score >6, % 9 

GAD-7; % Severe 33

Depression, Anxiety, Stress, % 

Mod-Extremely Severe 

Depression 24

Anxiety 32

Stress 16

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Preliminary Results

• No differences between groups

–Pain variables

–Psychological variables

• Both groups improved over time

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Pain Interference

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Pain Severity

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Depression

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Quality of Life: Mental Health

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Pain Outcomes: Negative Affect

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Conclusions

• Delivering a pain-based intervention as a 

component of PACT is feasible

• Telephone-based interventions for pain are 

feasible, acceptable

• Current study: both groups improved in pain 

and psychological variables

• Need to identify which elements are helpful

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A PC Intervention with Similar Results 

RCT (Carmody and colleagues, 2013)

• Telephone-delivered CBT intervention for 

chronic pain with veterans PC

– T-CBT compared to pain education

– 12 sessions of CBT over 20 weeks

• No significant differences in outcome 

measures. 

– Small but significant improvements in physical and 

mental health for both groups

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Potential Moderators?

• Differential responding

– Type of pain

– Personality

– Gender, age

– Fear, attention and vigilance

– Catastrophizing and worry

– Avoidance

– Coping style, etc.

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Possible Future Directions

• Increase emphasis on pain self-management 

rationale

– May be particularly important for patients with 

depression and anxiety

• Assess motivation for change

• Consider behavioral analysis of pain-related 

behaviors

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Future Directions: Increase emphasis 

on lifestyle modification?

• Recent RCT comparing pain coping skills + 

behavioral weight modification to each 

intervention individually (Somers et al., 2012) 

for obese pts with osteoarthritis

– Combined group led to better outcomes

• Current sample

– BMI mean = 31

– Borrow from MOVE and other lifestyle programs?

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Questions?

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Amy Helstrom, Ph.D.

Philadelphia VA Medical Center

3900 Woodland Ave.

Philadelphia, PA 19104

Amy.helstrom@va.gov

215-823-4164

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