Opening the Implementation Blackbox for Non-Pharmacologic Pain Interventions

Abstract

Musculoskeletal pain remains a pervasive public health challenge affecting over 80% of Americans with substantial economic costs1,2. Non-pharmacologic interventions such as physical therapy and cognitive-behavioral therapy are recommended as first-line treatments for musculoskeletal pain but face significant implementation barriers in clinical practice3,4. This dissertation investigated strategies to optimize the implementation of non-pharmacologic pain interventions in real-world settings.The first project explored the relationship between intervention complexity and adaptations across 24 pragmatic trials using the Intervention Complexity Tool for Embedded Pragmatic Clinical Trials (ICT-ePCT)5 and a survey analysis. Our findings suggest that intervention delivery complexity may be higher for pragmatic trials that are investigating non-pharmacologic pain interventions versus non-pain trials but only in very specific areas. Additionally, changes in workflow was an important consideration for intervention delivery for all trials in our study. Future research should capture detailed, real-time information about the nature of intervention delivery complexity, adaptions, and implementation success to help improve delivery of non-pharmacologic pain interventions. These findings underscore the importance of understanding and systematically documenting adaptations to enhance intervention fit within diverse healthcare environments. The second project investigated clinically relevant contextual factors influencing patient enrollment in multimodal LBP interventions across different healthcare centers. Using the Basel Approach for Contextual Analysis (BANANA), we quantitatively and qualitatively analyzed clinically relevant contextual factors such as number of referring providers and institutional characteristics6. This contextual analysis provided key insights into the influence of contextual factors on referral processes for low back pain care. While both pathways achieved their enrollment goals within a similar timeframe, there were several differences in relationships of contextual factors between the two pathways, highlighting the importance of using tailored implementation strategies in future studies. Our qualitative findings emphasize the significance of ongoing provider engagement and communication in enhancing referral processes. Additionally, beliefs about program effectiveness and referral priorities underscore the need for targeted educational interventions and provider training to optimize program adoption. The third project evaluated the feasibility of implementing an evidence-based pain cognitive-behavioral therapy (CBT) protocol among oncology nurses. Surveys and qualitative interviews explored nurses’ perceptions and barriers to implementing pain-CBT and revealed important insights into feasibility and acceptability within oncology settings. The study findings highlight specific opportunities for future research focused on the design and evaluation of interventions that use a nurse-specialist model of pain coping skills training for patients with cancer. Future studies should use a hybrid effectiveness-implementation design to (1) evaluate the impact of the nurse-specialist model on clinical pain outcomes and (2) test strategies for the initial training and ongoing support of nurse-specialists delivering the intervention. This project contributes valuable data on strategies to support effective implementation of behavioral pain management strategies. This dissertation contributes to bridging the gap between evidence and practice in non-pharmacologic pain interventions by systematically examining intervention complexity, contextual factors, and implementation outcomes. By elucidating the adaptation process and identifying facilitators of successful implementation, this research informs efforts to enhance the availability and effectiveness of recommended non-pharmacologic pain treatments in routine clinical care.