Background: This application is for a five-year Career Development Award (CDA) to support my transition to becoming an independent VA health services researcher. Career plan: To successfully achieve my career goal of improving Veterans' health and quality of life by enhancing the reach and effectiveness of behavioral sleep interventions, I need further mentored training and content expertise in chronic pain and health services research, including qualitative methodologies, pragmatic randomized trials, and implementation science, including social marketing theory. I will achieve these objectives through formal coursework, seminars, clinical training, and mentorship from Melissa Polusny, PhD (primary mentor; Minneapolis VA Health Care System, MVAHCS), Erin Krebs, MD, MPH (MVAHCS), Michael Vitiello, PhD (University of Washington), and Hildi Hagedorn, PhD (MVAHCS). Research plan:
Specific aims i nclude 1) understanding the experience of sleep treatment in comorbid chronic pain and insomnia, 2) optimizing cognitive behavioral therapy for insomnia (CBT-I) delivery for patients with chronic pain and insomnia, and 3) increasing demand for CBT-I among patients with chronic pain and their primary care providers. Projects include a qualitative interview study with patient and CBT-I provider dyads following completion or drop-out from CBT-I to inform hypotheses about strategies to eliminate barriers to adherence. I will use these findings to draft a package of adherence-promoting adaptations for patients with chronic pain. A pilot feasibility study will be used to finalize the adherence package and test feasibility of trial procedures to prepare for a future pragmatic randomized clinical trial. The final project is a local implementation study to test a social marketing campaign to increase demand for CBT-I among patients with chronic pain by increasing patient and primary care provider awareness and positive attitudes toward CBT-I. The social marketing campaign developed in this study will be an important component of a multifaceted implementation intervention that will be tested in a future multisite trial. The first two projects will result in a package of adherence-promoting adaptations to be added to CBT-I for patients with chronic pain. It is likely that components of the adherence package will inform broader efforts to enhance CBT-I adherence in all patients with insomnia, both those with and without chronic pain, as well as adherence to other cognitive behavioral therapies. The final CDA project will result in a social marketing campaign designed to increase demand for CBT-I among patients with chronic pain. We expect that components of the social marketing campaign can also be used as part of broader campaigns to disseminate CBT-I widely among patients with insomnia, leading to higher-rates of guideline-concordant care. Significance and innovation: CBT-I is a highly effective and safe treatment for improving sleep and pain outcomes and represents a promising alternative to pharmacologic treatments for pain and sleep, which are associated with serious adverse events. The proposed research utilizes intervention mapping and social marketing theories to identify evidence-based strategies to increase demand and optimize CBT-I delivery for patients with chronic pain. This work is responsive to calls by VA and national/international organizations to address barriers to full implementation of CBT-I and to enhance adherence to cognitive behavioral treatments.
I am applying for five years of mentored training and research. The proposed training and projects address a critical gap in chronic pain care. Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective and safe treatment for improving sleep and pain outcomes, yet is severely underutilized among patients with chronic pain. Evidence suggests that even if patients with chronic pain initiate CBT-I, they have difficulty adhering to treatment recommendations due to pain-specific barriers. The proposed research focuses on increasing demand and optimizing CBT-I delivery for patients with chronic pain. We expect that findings will have a broad impact on CBT-I dissemination and adherence, as well as adherence to cognitive behavioral therapies in general. I will obtain mentored training in qualitative research, pragmatic randomized trials, implementation science, and content expertise in chronic pain. This award supports my long-term career goal of improving Veterans' health and quality of life through effective sleep treatments.
