A new federal initiative will support three projects at the Yale School of Medicine and nine other projects designed to investigate nondrug treatments for pain in military personnel and veterans.

A collaboration between the National Institutes of Health, the Department of Defense and the Department of Veterans Affairs, the initiative will take place over six years and provide the 12 projects with a total of $81 million. All 12 projects will explore the feasibility and effectiveness of nondrug approaches to chronic pain.

“The undertreatment of pain and the lack of investigation into pain management is a huge public health problem,” said Robert Kerns, a professor at the Yale School of Medicine and psychologist in the VA Connecticut Healthcare System, who is co-leading one of the projects. “Combined with the opioid crisis that has emerged in this country, it’s particularly important to study nonpharmacological approaches — many of which have been shown to be of comparable or higher efficacy to opioid therapy.”

Chronic pain disproportionately affects military members and veterans. By focusing on nondrug treatments, the studies aim to address the national crisis of opioid abuse, which often results from excessive reliance on prescription painkillers.

Kerns explained that the treatments of interest can be divided into three broad categories: psychological and behavioral approaches, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction; movement and exercise interventions, including structured aerobic exercise, tai chi and yoga; and manual therapies, including acupuncture, massage and spinal manipulation.

According to the Centers for Disease Control and Prevention’s National Health Interview Survey, veterans are more likely to report pain and to report more severe pain than civilian populations. Their experiences during deployment leave them particularly vulnerable to stresses such as musculoskeletal conditions and post-traumatic stress disorder, according to Yale School of Medicine professor and VA Connecticut psychiatrist Marc Rosen, who will be co-leading another of the Yale projects.

Moreover, mental illness and substance abuse disorders, which occur more frequently among veterans than in civilian populations, are also risk factors for opioid abuse. Because of these risk factors, Kerns said the use of opioids to treat chronic pain may be detrimental for veterans, especially in the long term. Thus, determining the most effective nondrug approaches may be crucial in preventing cases of opioid abuse.

Kerns noted that, despite growing evidence of the efficacy of nondrug pain treatments, these strategies are not commonly prescribed or recommended by health care providers. A significant deterrent to the availability of these services is the issue of payment and reimbursement.

Of all the nondrug approaches, only three have specific procedure codes that Medicare, Medicaid and third-party payers can use to reimburse those services: acupuncture, massage and spinal manipulation. Therefore, Kerns hopes that these studies can encourage health care systems to reimburse more of these services by supporting their effectiveness in managing chronic pain.

One of the three projects at Yale will be the Pain Management Collaboratory Coordinating Center in collaboration with the National Center for Complementary and Integrative Health, a branch of the National Institutes of Health that studies treatments in lieu of or in combination with drugs.

According to Kerns, who will co-lead the center, it will help investigators to develop about a dozen clinical trials for nondrug approaches to address pain. He added that, while these approaches have shown strong evidence of efficacy in well-controlled randomized trials, the upcoming study will involve pragmatic trials, which will investigate implementation in real-world settings.

A second Yale project will test the effectiveness and cost-effectiveness of a brief intervention that encourages veterans to seek these nondrug treatments. The researchers will work with all eight VA medical centers in New England by randomizing 1,200 veterans to receive either usual care or an intervention when they apply for service-related pain compensation, which is often the point of entry into the VA system.

“Early intervention that engages these veterans in nondrug treatments that are complementary with their medical care could help arrest worsening pain and risky substance use,” said medical school professor and VA Connecticut Chief of Psychology Steve Martino, who is co-leading the project with Rosen.

Finally, medical school professor and Associate Director of VA Connecticut’s Pain Research, Informatics, Multimorbidities and Education Center Alicia Heapy will lead a project studying the health outcomes of a technology-based remote form of cognitive behavioral therapy compared to in-person therapy.

Technology-based interventions may provide more equitable and timely access to nondrug approaches, since they circumvent barriers to in-person care, such as travel limitations and a lack of therapists.

About 50 percent of veterans and 45 percent of service members suffer from pain regularly, according to the NIH.

Amy Xiong | amy.xiong@yale.edu