The proposed study will test the efficacy of an innovative method, interactive voice response (IVR), for delivering an empirically validated psychological treatment (cognitive behavior therapy [CBT]) for chronic low back pain in order to improve accessibility to veterans. IVR is a computerized interface that allows patients to use their telephone to: 1) obtain pre-recorded didactic information, 2) report data regarding pain-related symptoms and adherence to pain coping skill practice, and 3) receive personalized therapist feedback. Although CBT has been shown to be effective in reducing pain intensity, disability, and affective distress in two meta- analyses, traditional CBT is time intensive for therapists and requires patients to make frequent office visits. The use of IVR will allow veterans to access CBT from their home via a touch-tone telephone, thereby allowing them to access treatment at their convenience without travel to the VA for an outpatient appointment. Veterans with chronic low back pain will be randomized in equal numbers to receive either standard CBT or IVR-based CBT. The primary outcome measure will be pain intensity. Secondary outcome measures will be quality of life and physical and emotional functioning. Study participants will be evaluated pre-treatment (baseline), 12 weeks post-baseline (post-treatment) and at 3 and 6 months post-baseline (follow-up). Exploratory objectives of the study are to examine: (1) factors other than clinical outcomes on which the treatments may differ (drop-out rate, treatment satisfaction, treatment credibility, and behavioral goal accomplishment); and (2) moderators (e.g., age, sex, race/ethnicity, pain site location and number, medication use and psychiatric comorbidities) of treatment engagement and participation, adherence to therapist recommendations for pain coping skill practice and outcomes.
Making CBT accessible to more veterans is especially important considering that several studies demonstrate the high prevalence and costs of chronic low back pain (CLBP) among veterans receiving care in VHA facilities. Chronic pain is often accompanied by social and psychological difficulties including loss of work, and declines in social, emotional and physical functioning. Persons with chronic pain often have co-occurring medical and psychiatric conditions and emerging data suggests that chronic pain may undermine management of these disorders. The VHA Health Economics Research Center has documented particularly high costs of care for veterans with CLBP. Given the high prevalence and cost of CLBP, and its association with decrements in the management of other chronic conditions, increasing the availability of treatments for chronic pain would likely assist in optimizing care to this population.