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June 25, 2026
By Marcus Henry
VA Research Communications
When a Veteran is ready to start treatment, we want there to be a convenient, evidence-based treatment they can start without waiting for an appointment. (Dr. Alicia Heapy)
Chronic musculoskeletal pain is one of the most common conditions of Veterans at VA, and cognitive behavioral therapy for chronic pain, known as CBT-CP, is a first-line treatment that works without medication. However, travel, scheduling conflicts, the burden of multiple visits, or a limited supply of trained clinicians can keep many Veterans from ever starting it, so VA researchers created an alternative.
A VA-led randomized trial of 764 Veterans found that a self-directed version of CBT-CP, delivered through daily automated phone calls and weekly feedback from a coach, was more effective than standard clinician-delivered therapy. The results, published June 24 in JAMA, showed Veterans in the self-directed program started treatment faster, completed more of it, and reported greater improvement in how much pain interfered with their daily lives.
“We did hypothesize [the self-directed program] would be superior,” said Dr. Alicia Heapy, a research psychologist at VA Connecticut Healthcare System and co-director of VA ORD’s Pain/Opioid Consortium of Research (CORE). “It’s easier for patients to do, so they probably, on average, get a larger dose of treatment.”
The trial ran from December 20, 2019, to February 20, 2024, across nine VA health care systems, with follow-up through February 2025. Participants were randomly assigned to either the self-directed program, called COPES, short for Cooperative Pain Education and Self-management, or to clinician-delivered CBT-CP under usual practice conditions. The clinician version ran as weekly sessions, typically four to 11 of them, most often by video. The group reflected the patients VA clinicians normally see: an average age of nearly 53, more than a third of them women, with roughly a quarter living in rural areas and most carrying multiple pain sites, with many also living with insomnia or a mental health condition such as depression or PTSD.
Heapy led the trial with co-principal investigator Diana Higgins, PhD, a clinical health psychologist at VA Connecticut Healthcare System.
COPES participants received a handbook and learned one pain-management skill each week, the same skills taught in clinician-delivered CBT-CP. Each day they answered a short automated call, about a minute long, reporting on their pain, sleep, activity, and skill practice. At the end of each week, a coach reviewed that data and recorded a two- to four-minute message with personalized feedback. Participants also got a pedometer and a walking goal that increased gradually over time.
Heapy said the daily calls and coaching turned out to be central, not incidental.
“When we went into this, I think we maybe didn’t fully understand the therapeutic aspects of this daily calling and feedback,” she said.
The routine built in self-monitoring, accountability, and reinforcement, and it lets coaches point out patterns a Veteran might miss. A coach might note, “I noticed that your pain was lower on Wednesday. Can you think about what was happening that day?”
“I liked how involved the coach was. I love that he sounded sincere. He was very honest about everything in his feedback about what I needed to do. Honestly it was just a really good experience.”
- Feedback from a Veteran in the self-directed group
At four months, Veterans in COPES reported less pain interference than those in clinician-delivered care, with mean scores of 5.26 versus 6.23 on a 10-point scale. The difference was statistically clear but small, near the threshold researchers consider clinically meaningful on its own. The advantage held at 6 and 12 months.
Heapy said she is wary of leaning on any single number. Chronic pain affects mood, sleep, and activity at once, so the honest test is the pattern across them. By that measure the trial was consistent: the self-directed group did better on sleep, depression, pain catastrophizing, self-efficacy, and overall impression of change, and that edge held for 12 months after the therapy.
“Even after they’re out of active treatment, they continue to have benefit,” Heapy said. “They learned the skills, and they’ve likely kept doing the ones that work for them.”
More of them also cleared the bar for a clinically meaningful change. On pain interference, 38% of self-directed participants reached at least a moderate improvement of 30% or more, compared with 17% of those in clinician-delivered care. The self-directed group came out ahead under every threshold the team examined, including access to therapy.
COPES participants started treatment in a median of 16 days, compared with 41 days for clinician-delivered care, and they completed more of their expected sessions. Because coaches worked from a central location and no appointment was required, Heapy said, Veterans could begin whenever they decided they were ready.
“When a Veteran is ready to start treatment, we want there to be a convenient, evidence-based treatment they can start without waiting for an appointment,” she said.
“It was an easy program, especially doing it from home. And getting a daily phone call, which really weren’t that long. You could set the time that would fit into your lifestyle.”
- Feedback from a Veteran in the self-directed group
It is important to note that the study results do not invalidate clinician-delivered CBT-CP. According to Heapy, many Veterans prefer working one-on-one with a clinician or have more complex needs that call for it. Having an alternative does not make that therapy any less effective or valuable.
“What I think is that, as a system, we want both,” she said.
Offering a centrally delivered, self-directed option alongside local clinician care gives VA more flexibility, she added, and meets a range of Veteran preferences while easing wait times.
The work fits into a broader shift in pain care. Opioids are no longer considered a first-line treatment for chronic pain, and VA encourages non-drug, multimodal approaches.
“It’s really important to have high-quality non-pharmacological interventions that are easy for Veterans to do, are convenient, and that they like,” Heapy said.
The trial was funded by the National Institutes of Health as part of the Pain Management Collaboratory, a joint effort of NIH, the Department of Defense, and VA to run large pragmatic studies under real-world conditions. Heapy said VA’s integrated system made it possible to test the program across nine sites with broad eligibility, reaching the kind of complex patients who are often screened out of tightly controlled trials, including Veterans with alcohol or substance use disorders. Her two earlier COPES studies, both VA-funded, established that the approach was at least as good as in-person care and laid the groundwork for this larger trial.
“VA is one of the few places where you can deliver something centrally to any facility across the whole country,” she said. “That’s a big reason for wanting to do these self-directed treatments. They can be scaled in a really meaningful way.”
That scaling is already underway. In close coordination with VA’s Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP), COPES is now being rolled out as a clinical program in VISN 1, VA’s New England region, with a plan for an eventual national rollout.
The study results appeared in the journal JAMA.
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