Veterans Administration

Grand Rounds October 2, 2026: Self-Directed Versus Clinician-Delivered Cognitive Behavioral Therapy for Chronic Pain: Results From the COPES ExTRA Pragmatic Trial (Alicia Heapy, PhD; Diana Higgins, PhD)

Posted on by Sophia Ramirez

Speakers

Alicia Heapy, PhD
Associate Professor
Yale School of Medicine
Department of Psychiatry
Co-Director VA Pain/Opioid Consortium of Research
VA Connecticut Healthcare System

Diana Higgins, PhD
Clinical Psychologist
MBHI-Neurology
VA Connecticut Healthcare System

Keywords

Chronic Pain; Cognitive Behavioral Therapy; Veterans Administration; Superiority Trial; Barriers

Key Points

  • Cognitive behavioral therapy for chronic pain (CBT-CP) is an underutilized first-line treatment that improves pain and functional outcomes. Barriers to use remain, from patient barriers like the need to travel and mobility issues to system barriers like clinician scarcity and the prevalence of pain.
  • COPES ExTRA was a pragmatic, hybrid type 1 superiority trial that sought to assess the effectiveness of self-directed CBT-CP relative to clinician-delivered CBT-CP among adults with chronic musculoskeletal pain. The research team sought to evaluate the strengths and weaknesses of each approach and inform future clinical use of CBT-CP in the Veterans Health Administration.
  • They found that, while both arms saw clinically significant improvements, patients who received self-directed CBT-CP showed superior improvements on pain interference, pain intensity, sleep, and depressive symptoms durable to 12 months. Convenient, scalable self-directed CBT-CP may be an effective alternative to clinician-directed therapy.
  • Self-directed participants waited fewer days to start treatment and attended more treatment sessions. Factors that contributed to the success of self-directed CBT-CP included fidelity or consistency; the therapeutic elements of daily diary/feedback; walking; and faster time to treatment.

Discussion Themes

Pragmatic methods yielded a sample representative of patients receiving care in the Veterans Health Administration.

Adapting the model outside integrated health systems faces major billing and administrative hurdles, particularly regarding CPT coding and insurance reimbursement for asynchronous coaching.

Standardized effect sizes reached 0.43–0.44 for the primary outcome and 0.3–0.4 across secondary measures, comparing favorably to or exceeding effect sizes typically achieved in non-pharmacological chronic pain trials.

Recruiting and onboarding clinical sites required extensive effort; some clinicians were wary of automated electronic health record alerts generating overwhelming surges in patient referrals or impacting workload metrics.

Grand Rounds February 20, 2026: Applying Mind-Body Skills for Pain Using a Whole Health Telehealth Intervention (RAMP): Early Progress and Lessons Learned (Diana Burgess, PhD; Roni Evans, DC, MS, PhD; Katie Hadlandsmyth, PhD)

Posted on by Sophia Ramirez

Speakers

Diana Burgess, PhD
Professor of Medicine,
University of Minnesota
Director, VA Advanced Fellowship Program in Health Systems Research, Center for Care Delivery and Outcomes Research (CCDOR),
Minneapolis Veterans Affairs Healthcare System
Director, QUERI Complementary and Integrative Health Evaluation Center (CIHEC),
Veterans Affairs Healthcare System

Roni Evans, DC, MS, PhD
Research Professor
Director, Integrative Health & Wellbeing Research Program
Earl E. Bakken Center for Spirituality & Healing,
University of Minnesota

Katie Hadlandsmyth, PhD
Associate Professor
College of Nursing
University of Iowa

Keywords

Chronic Pain; Whole-Health; Biopsychosocial; Veterans Administration (VA); Rural Populations

Key Points

  • Rural Veterans exist at the intersection of 2 populations that are disproportionately affected by chronic pain. Compared to urban Veterans, rural Veterans are less likely to receive comprehensive and specialty pain care; are more likely to be prescribed opioid medication; and utilize pain self-management strategies at lower rates. The Veterans Administration (VA) serves 2.7 million rural veterans.
  • Seeking to improve pain management and reduce opioid use among rural patients, VA researchers developed the Rural Veterans Applying Mind Body Skills for Pain (RAMP) intervention. RAMP addresses pain as a biopsychosocial condition, providing rural VA patients with the opportunities and resources to enhance their capabilities and motivations to engage in helpful pain self-management behaviors.
  • A pilot study found that the intervention met milestones for enrollment, satisfaction, and fidelity. The researchers concluded that a full-scale randomized trial of a complementary and integrative health telehealth program for rural VA patients with chronic pain is feasible and can meet pain self-management needs. Their intervention and study processes have been refined to increase engagement and data collection.
  • In March 2026, the team will begin enrollment for a Type II randomized hybrid-effectiveness implementation trial.

Discussion Themes

The team emphasized the need for “resilient interventions” that can withstand external disruptions, such as natural disasters and VA workforce restructuring.

Relationship-building with high-level and local stakeholders was essential for navigating the VA’s complex and dynamic organizational structure. The researchers detailed their strategy for managing stakeholder panels, which included roughly 21 core members (i.e., patients and community advisors) and 10 internal VA stakeholders.