Motivational Interviewing Targeting Pain and Substance Use in Veterans Seeking Service-Connection Payments: A Multisite Randomized Clinical Trial

Abstract

Background: Veterans filing musculoskeletal disorder (MSD) service claims may also be seeking medical treatment.

Objective: To determine the effect of Motivational Interviewing to Activate Pain Support (MAPS) on pain and substance use in veterans who recently filed MSD claims.

Participants: A total of 1101 post 9/11 veterans who had filed MSD compensation claims, were not receiving multimodal pain care from VA and had at least moderately severe pain.

Interventions: Up to five phone sessions of MAPS compared to treatment-as-usual (TAU).

Main measures: Pain severity subscale of the Brief Pain Inventory (BPI) and number of substances above the low-risk threshold of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

Key results: Most (87%) veterans offered MAPS participated, and counselors delivered MAPS with good integrity. At week 36, MAPS participants had significantly greater reductions in pain severity than TAU (-0.78 vs. -0.53; mean difference = -0.25, 95% CI -0.44 to -0.06, p = .011), although rates of clinically meaningful improvement were similar between groups (45.4% MAPS vs. 40.8% TAU; OR = 1.21, 95% CI 0.92-1.59, p = .183). The groups did not differ in self-reported number of pain treatment modalities used (TAU = 3.01 modalities vs. MAPS 3.33 modalities, p = .135); however, MAPS participants had, on average, 54% more outpatient encounters for MSDs than those in TAU (MAPS 7.25 vs. TAU 4.58, p < .001). Substance use did not differ between groups.

Conclusions: MAPS was associated with more outpatient encounters for MSD and statistically significant reductions in pain severity at week 36; reductions achieving the threshold for clinical significance did not differ by group. Benefits from MAPS, despite pandemic-era disruptions to treatment availability, may have occurred via counselors activating patients to seek MSD treatments, helping them navigate pain care systems, and offering patients support.

Design: Two-arm, parallel group 36-week multisite randomized pragmatic clinical trial (Clinical Trials.gov: NCT04062214).

Trial registration: ClinicalTrials.gov registration (NCT04062214) on August 19, 2019.

Keywords: Veterans; compensation; counseling; disability; motivational interviewing; pain; service-connection; substance use.