Optimizing Response to Chronic Pain Treatments in Veterans: Identifying Key Moderators

Abstract Chronic pain is a prevalent, disabling problem affecting as many as 50% of men and 75% of women Veterans. There is widespread recognition of the importance of developing effective complementary and integrative health (CIH) treatments and the need to optimize their effectiveness. The CIH pain treatment with the most empirical support is cognitive-behavioral therapy (CBT). However, not everyone benefits from CBT. Prior research has shown that two CIH interventions, Mindfulness-Based Cognitive Therapy (MBCT) and Hypnotic Cognitive Therapy (HYP-CT), are beneficial and offer alternatives to CBT and have similar efficacy. However, as with CBT, individual response to these treatments also varies considerably. Our preliminary data suggests the variability in treatment outcome may be due to important baseline patient differences. This suggests the possibility that patients can be effectively “matched” to the treatments they are most likely to benefit from, based on information that can be obtained before treatment starts. Research is needed to develop patient-treatment matching algorithms that could match a given individual to the evidence-based treatment most likely to be beneficial given their unique individual profile. The overall aim of the proposed study is to address this need by identifying patient factors that determine who benefits most from two CIH treatments and the current gold standard non-pharmacological treatment (CBT), relative to usual care. This aim will be addressed using a clinical trial in which participants will be randomized to one of the four treatment conditions. We will test hypotheses – developed from both theory and prior pilot research – that pre-treatment brain activity patterns, hypnotizability, catastrophizing, and mindfulness moderate pre- to post-treatment improvements in pain intensity associated with group-delivered CBT, MBCT, and HYP-CT, relative to usual care, in Veterans with chronic pain. The findings will provide the foundation for building an algorithm to support personalized care, whereby Veterans can be offered the treatment that will be most beneficial for them. This study will also help develop knowledge about potentially powerful alternatives to pharmacological/opioid analgesic approaches. Finally, the study findings will be useful to health care providers and their patients to facilitate shared decision-making.