Optimizing Psychotherapy for Older Veterans With Chronic Pain
Condition: Musculoskeletal Pain
MeSH terms: Musculoskeletal Pain; Chronic Pain
Study type: Interventional

Summary: 
      This study is being performed to compare the effects of two alternate types of psychotherapy,
      Cognitive Behavior Therapy (CBT) and Emotional Awareness and Expression Therapy (EAET), for
      chronic musculoskeletal pain in older adults. In addition, the investigators will evaluate
      which patients respond better to each treatment and further investigate how each treatment
      works. CBT, which focuses on improving coping skills for pain, is the standard form of
      psychotherapy offered at VA. EAET instead focuses on understanding how life stress,
      relationships, and emotions may cause and perpetuate pain.

      The investigators are performing the study because pain is a large problem among Veterans.
      Studies show that chronic pain affects as many as 50% of male Veterans and 75% of female
      Veterans. The investigators are focusing on older adult Veterans because they have the
      highest rates of chronic pain at VA, perhaps as high as 80%. The investigators are looking at
      psychotherapy in this study because VA, the Department of Defense, and the CDC recently
      recommended psychosocial treatments, such as psychotherapy, as first treatments for chronic
      pain, along with medications other than opioids (e.g., oxycodone). However, only one form of
      psychotherapy, CBT, is currently available in clinical practice at VA, and this study may
      provide evidence for making EAET available to Veterans as well.
    

Detailed description: 
      The overarching goal of the proposed research is to learn how to optimize psychotherapy for
      those Veterans most in need and most likely to benefit from psychotherapy, older Veterans
      with chronic musculoskeletal pain. Chronic pain is a critical healthcare challenge, as the
      condition affects 50% of all Veterans and affects older Veterans most commonly, severely, and
      persistently. For years, chronic pain treatment has been notoriously difficult at VA and
      elsewhere, especially in light of the recent "opioid crisis," in which opioid analgesics,
      previously a mainstay of chronic pain treatment, have come under increased scrutiny. In
      response, CDC, VA/DoD, and some experts have called for enhancing and expanding psychosocial
      treatment options for chronic pain, such as psychotherapy, which are low risk for older
      Veterans who frequently have multiple medical comorbidities and are taking multiple
      medications.

      Yet standard VA psychotherapy approaches, such as Cognitive Behavior Therapy (CBT), have
      shown modest benefits for Veterans on pain and other related outcomes, such as mood, anxiety,
      and sleep. In contrast, a novel psychotherapy approach, Emotional Awareness and Expression
      Therapy (EAET), has shown medium to large benefits for some chronic pain patients. Whereas
      CBT improves pain and negative emotion by teaching patients cognitive and behavioral coping
      skills, affecting brain regions that enhance "cognitive control" of pain, EAET operates
      primarily through emotion regulation, which is thought to influence brain regions and
      circuits that modulate both physical pain and emotion-a mechanism absent from existing
      approaches. The literature and the investigators' pilot data indicate that patients who
      express emotional distress at baseline, such as high anxiety and depressive symptoms, may be
      particularly likely to benefit from EAET's emotion regulation approach, whereas patients who
      express less emotional distress may derive more benefit from an approach like CBT, which does
      not require ready access to emotions.

      The proposed randomized clinical trial tests the hypothesis that EAET is superior to CBT on
      reduction in mean pain severity and other outcomes derived from IMMPACT. To examine which
      patients are most likely to benefit, this research also tests whether greater baseline
      emotional distress (using measures of anxiety and depression) predicts stronger benefits from
      EAET and whether lower baseline emotional distress predicts stronger benefits from CBT.
      Finally, this research explores whether the benefits of EAET are mediated by improved emotion
      regulation, whether the benefits of CBT are mediated by improved cognitive and behavioral
      coping, and whether the benefits of both are mediated by a stronger working alliance. The
      investigators plan to enroll 160 multi-ethnic/multi-racial older Veterans (age 60-95 years)
      with chronic musculoskeletal pain at the West Los Angeles VA Medical Center.

      This research can introduce an additional, potentially more effective format of psychotherapy
      at VA so that more Veterans with chronic pain can respond. In addition, this research can
      lead to better treatment targeting and enhance the understanding of how psychotherapy
      treatments work. Finally, this research can facilitate the development of critical skills for
      the PI in psychotherapy research and pain management and enhance his ability to effect
      positive change for older Veterans.

      Recruitment was resumed after the COVID-19 Administrative Hold was lifted in October 2020.
    

Intervention name(s): Emotional Awareness and Expression Therapy; Cognitive Behavior Therapy
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Focus on emotions, writing about stress, assertiveness training, role playing new ways to handle relationships, and sharing feelings and experiences with others.; Focus on cognitive and behavioral skills, such as relaxation, increasing pleasant activities, pacing, and changing ways of thinking.
Other intervention name(s): EAET; CBT
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Two-Group Parallel Comparison Trial
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Chronic Pain; Psychotherapy; Musculoskeletal Disease