Pragmatic Trial of WHT vs. PC-GE to Promote Non-Pharmacological Strategies to Treat Chronic Pain in Veterans

NCT04330365 | Completed Results DMC

• 1 other identifier: UH3AT009765
• Study Type: interventional
• Target: 793
• Locations: 1 country
• Sites: 6

Brief Summary

The overarching goal of this Pain Management Collaboratory Demonstration project is to test a new Whole Health paradigm for chronic pain care, emphasizing non-pharmacological pain self-management that is hypothesized to reduce pain symptoms and improve overall functioning and quality of life in Veterans. In UH3 Aim 1, the investigators will conduct a 12-month pragmatic effectiveness trial at 6 VA sites across the country to test whether veterans with moderate to severe chronic pain randomized to receive the Whole Health Team (WHT) intervention are more likely than those receiving Primary Care Group Education (PC-GE) to: Hypothesis 1: Experience improved pain interference (primary outcome), pain intensity, functioning and quality of life (secondary outcomes); Hypothesis 2: Decrease use of higher-risk pain medications, including opioids, or high-risk combinations; Hypothesis 3: Engage in a greater number of non-pharmacological pain management activities; and Hypothesis 4: Experience improved mental health-related symptoms, including sleep problems and suicidality. In addition, both the WHT and PC-GE arms will be compared to a third group of veterans randomized to Usual Primary Care (UPC, Control) on the same primary and secondary outcomes above. After the baseline assessment, masked telephone assessments will be administered to participants at 3, 6, 9, and 12 months. UH3 Aim 2 is to conduct a process evaluation of the two active interventions (WHT and PC-GE) and a budget impact analysis that includes costs to implement and execute the two active interventions as well as the control condition (UPC) to inform the development of an implementation toolkit for scaling and dissemination. Eligible participants are veterans reporting moderate to severe chronic pain present every day or nearly every day for ≥ 6 months. The total sample size for the population is based on our main study aim/hypothesis and is N=764. This breaks down to n=343 in the WHT intervention, n=339 in the PC-GE intervention, and N=82 in the Usual Primary Care arm (Control). Results of this UG3/UH3 Pain Management Collaboratory Demonstration project will contribute to the overall mission of the NIH/VA/DoD initiative to build national-level infrastructure that supports non-pharmacologic pain management in veterans and military service personnel.

Conditions

Chronic Pain

Outcome Measures

Primary Outcomes (1)

• Change in Pain Interference

  The total Brief Pain Inventory (BPI) interference sub-scale score is our primary outcome measure. Pain interference was calculated as the mean of the 7 pain-interference items (scale ranged 0-10; higher scores indicate greater pain interference).

  12 months

Secondary Outcomes (14)

• Change in Pain Severity

  12 months

• Functioning (VR-12 Physical Component Score)

  12 months

• Quality of Life (VR-12 Mental Component Score)

  12 months

• PROMIS Sleep Disturbance

  12 months

• Engagement in a Greater Number of Non-pharmacological Pain Management Activities

  12 months

Study Arms (3)

Whole Health Team (WHT) Intervention Arm

ACTIVE COMPARATOR

The WHT intervention arm includes four core elements: 1) An interdisciplinary WHT collaborating with primary care; 2) Personalized Health Planning with prioritization of multi-modal non-pharmacological and CIH pain management approaches; 3) Whole Health Coaching sessions to assist patients in developing and implementing a Personalized Health Plan for chronic pain care; and 4) the web/mobile Whole Health Resource Directory provided to patient participants (in addition to their providers) to support non-pharmacologic/CIH chronic pain care.

Behavioral: Whole Health Team (WHT) Intervention Arm, Primary Care Group Education (PC-GE) Intervention Arm, Usual Primary Care (UPC) Arm

Primary Care Group Education (PC-GE) Intervention Arm

ACTIVE COMPARATOR

Primary Care Group Education (PC-GE) is the comparator arm, which is an abbreviated form of Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) adapted for group use in primary care.

Behavioral: Whole Health Team (WHT) Intervention Arm, Primary Care Group Education (PC-GE) Intervention Arm, Usual Primary Care (UPC) Arm

Usual Primary Care (UPC) Arm

PLACEBO COMPARATOR

In VA, patient-aligned care teams (PACTs) or primary care is step 1 of VA's Stepped Care Model in the treatment of chronic pain. PCPs are expected to possess the requisite skill set for management of common chronic pain-causing conditions, which includes biopsychosocial assessment, multi-modal treatment, and coordination of specialty pain care after shared-decision making that incorporates patient preferences and values. Participants randomized to this arm will continue to have their PCP and PACT serve in this role.

Behavioral: Whole Health Team (WHT) Intervention Arm, Primary Care Group Education (PC-GE) Intervention Arm, Usual Primary Care (UPC) Arm

Interventions

Whole Health Team (WHT) Intervention Arm, Primary Care Group Education (PC-GE) Intervention Arm, Usual Primary Care (UPC) Arm BEHAVIORAL

Participants will be randomly assigned at the individual level to either WHT, PC-GE or Usual Primary Care, stratified by site, sex, and use of prescribed opioids for chronic pain. The follow-up period for the three arms will be 12 months. The primary outcome is change in pain interference. Secondary outcomes include change in pain intensity, functioning, quality of life, changes in use of pain medications, including opioids (if applicable) and changes in nonpharmacological pain self-management activities. After the baseline assessment, masked telephone assessments will be administered to participants at 3, 6, 9, and 12 months.

Primary Care Group Education (PC-GE) Intervention Arm; Usual Primary Care (UPC) Arm; Whole Health Team (WHT) Intervention Arm

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Assigned to a VA PCP;
• Report pain present every day or nearly every day for ≥ 6 months using a phone eligibility screener; and
• PEG score of ≥ 5 (including at baseline assessment)

You may not qualify if:

• Moderate or severe cognitive impairment as determined by a failed 6-item, validated cognitive screener on initial phone screening (See Appendix A: Telephone Eligibility Screen/Script);
• Active suicidality as determined by medical record review, standardized assessment (PHQ-9) and/or is unable to attend study visits because of an unstable or severe psychiatric or medical condition or is receiving palliative or hospice care; or
• Any other factors that would interfere with study participation including inability to communicate by telephone, VTEL or VVC; being a non-English speaker; plans to relocate within 12 months and concurrent participation in another pain-related study.

Sponsors & Collaborators

• San Francisco Veterans Affairs Medical Center: lead
• National Center for Complementary and Integrative Health (NCCIH): collaborator

Study Sites (6)

SFVAHCS

San Francisco, California, 94121, United States

Location

VA Connecticut

West Haven, Connecticut, 06516, United States

Location

James A. Haley Veterans Hospital

Tampa, Florida, 33612, United States

Location

Bedford VAMC

Bedford, Massachusetts, 01730, United States

Location

VA St. Louis Health Care System

St Louis, Missouri, 63125, United States

Location

VAPHCS

Portland, Oregon, 97239, United States

Location

Related Publications (7)

• Purcell N, Becker WC, Zamora KA, McGrath SL, Hagedorn HJ, Fabian ER, McCamish N, Seal KH. Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings. Med Care. 2020 Sep;58 Suppl 2 9S(Suppl 2 9 Suppl):S80-S87. doi: 10.1097/MLR.0000000000001376.

  PMID: 32826776 BACKGROUND

• Tong G, Seal KH, Becker WC, Li F, Dziura JD, Peduzzi PN, Esserman DA. Impact of complex, partially nested clustering in a three-arm individually randomized group treatment trial: A case study with the wHOPE trial. Clin Trials. 2022 Feb;19(1):3-13. doi: 10.1177/17407745211051288. Epub 2021 Oct 24.

  PMID: 34693748 BACKGROUND

• Seal KH, Becker WC, Murphy JL, Purcell N, Denneson LM, Morasco BJ, Martin AM, Reddy K, Iseghem TV, Krebs EE, Painter JM, Hagedorn H, Pyne JM, Hixon J, Maguen S, Neylan TC, Borsari B, DeRonne B, Gibson C, Matthias MS, Frank JW, Krishnaswamy A, Li Y, Bertenthal D, Chan A, Nunez A, McCamish N. Whole Health Options and Pain Education (wHOPE): A Pragmatic Trial Comparing Whole Health Team vs Primary Care Group Education to Promote Nonpharmacological Strategies to Improve Pain, Functioning, and Quality of Life in Veterans-Rationale, Methods, and Implementation. Pain Med. 2020 Dec 12;21(Suppl 2):S91-S99. doi: 10.1093/pm/pnaa366.

  PMID: 33313734 BACKGROUND

• Seal KH, Feinberg T, Moore L, Woodruff NA, Purcell N, Bertenthal D, McCamish N, Becker WR. Natural Product Use for Chronic Pain: A New Survey of Patterns of Use, Beliefs, Concerns, and Disclosure to Providers. Glob Adv Integr Med Health. 2025 Feb 27;14:27536130251320101. doi: 10.1177/27536130251320101. eCollection 2025 Jan-Dec.

  PMID: 40026674 RESULT

• Moore LC, Woodruff NA, Seal KH, Feinberg T, Purcell N. Natural Product Use Among Veterans with Chronic Pain: A Qualitative Study of Attitudes and Communication with Healthcare Providers. J Gen Intern Med. 2024 Sep;39(12):2206-2214. doi: 10.1007/s11606-024-08746-2. Epub 2024 Apr 30.

  PMID: 38689119 RESULT

• Denneson LM, Purcell N, McGrath SL, Abadjian LR, Becker WC, Seal KH. Integration of Health Coaches in a Whole Health Team Model of Chronic Pain Care: a Qualitative Study. J Gen Intern Med. 2023 Dec;38(16):3574-3580. doi: 10.1007/s11606-023-08317-x. Epub 2023 Jul 18.

  PMID: 37464147 RESULT

• Seal KH, Morasco BJ, Martin AM, Reddy KP, Van Iseghem TM, Bolton RE, Bokhour BG, Murphy J, Denneson LM, Esserman D, Buta E, Purcell N, Bertenthal D, Painter JT, Abadjian LR, Moore LC, Chan AC, McCamish N, Maguen S, Neylan TC, Gibson CJ, Becker WC; wHOPE Study Group. The Veteran Affairs' Whole Health Approach for Chronic Pain Management: The wHOPE Randomized Clinical Trial. JAMA. 2026 Apr 29:e265006. doi: 10.1001/jama.2026.5006. Online ahead of print.

  PMID: 42054020 DERIVED

MeSH Terms

Conditions

Chronic Pain

Condition Hierarchy (Ancestors)

Pain; Neurologic Manifestations; Signs and Symptoms; Pathological Conditions, Signs and Symptoms

Limitations and Caveats

Generalizability of this study is limited to a veteran population that was predominantly White and male. Only a small proportion of those assessed for eligibility enrolled. There was unmeasured variability across sites that is inherent in pragmatic trial design. Clinicians and patients were not masked, and the patient-reported outcomes may have been influenced by patients' knowledge of group assignment. As a pragmatic trial, study group interventions were not balanced for time and attention.

Results Point of Contact

• Title: Karen H. Seal, MD, MPH (Contact Principal Investigator)
• Organization: University of California, San Francisco (UCSF)

karen.seal@ucsf.edu

(415) 221-4810

Study Officials

• Karen H Seal, MD

  San Francisco VA Health Care System

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: No
• Restrictive Agreement: No

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: TREATMENT
• Intervention Model: SINGLE GROUP
• Sponsor Type: FED
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Chief of Integrative Medicine

Study Record Dates

• First Submitted: March 23, 2020
• First Posted: April 1, 2020
• Study Start: September 15, 2020
• Primary Completion: January 23, 2025
• Study Completion: January 23, 2025
• Last Updated: June 2, 2026
• Results First Posted: June 2, 2026

Record last verified: 2026-05

Data Sharing

• IPD Sharing: Will not share

Locations

US (6)