The Veterans Affairs' Whole Health Approach for Chronic Pain Management: The wHOPE Randomized Clinical Trial

Clinical Snapshot

Key Findings

• P Value: Whole Health vs CBT: P=0.02; Whole Health vs Usual Care: P=0.002; CBT vs Usual Care: P=0.46

• Effect Size: Whole Health vs CBT: -0.58 points; Whole Health vs Usual Care: -0.77 points

• Primary Outcome: BPI-I score improvement: Whole Health -1.7 points, CBT -0.9 points, Usual Care -0.7 points

• Nnt Or Sensitivity: Effect sizes below MCID of 1.0 point, suggesting limited clinical benefit despite statistical significance

• Confidence Interval: Whole Health vs CBT: 97% CI -1.11 to -0.05; Whole Health vs Usual Care: 99% CI -1.40 to -0.15

Clinical Application

Requires significant healthcare system investment in interdisciplinary teams including physicians, integrative medicine specialists, and health coaches Relevant to Australian integrated pain services and multidisciplinary chronic disease management programs, though resource requirements may limit implementation outside major centres. Aligns with RACGP chronic pain management guidelines emphasising multidisciplinary approaches Veterans and potentially other patients with chronic pain in integrated healthcare systems with multidisciplinary resources

Abstract

IMPORTANCE: The US Department of Veterans Affairs (VA) Whole Health approach was congressionally mandated in 2016 for patients with chronic pain receiving care in VA hospitals, but no randomized clinical trials have tested its benefits. OBJECTIVE: To evaluate the effectiveness of a whole health team intervention in VA patients with chronic pain compared with cognitive behavioral therapy and with usual care, and to evaluate the effectiveness of cognitive behavioral therapy compared with usual care in reducing long-term pain interference. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial involving 6 VA health systems in the US enrolled participants between September 18, 2020, and January 19, 2024. Final follow-up occurred on January 27, 2025. Analyses took place between April 1, 2025, and February 3, 2026. Participants were patients with chronic pain receiving VA primary care. INTERVENTIONS: Patients with chronic pain were randomized (11:11:2) to receive a whole health team intervention (n = 343), cognitive behavioral therapy for chronic pain delivered in group sessions (n = 339), or usual care (n = 82) for 12 months. The whole health team included a primary physician or nurse practitioner, a second clinician providing nonpharmacological or integrative pain care, and a coach. The team provided interdisciplinary, individualized care consistent with the VA Whole Health model to attain personal health goals aligned with patients' personal values and life goals. MAIN OUTCOMES AND MEASURES: The primary outcome was the Brief Pain Inventory interference (BPI-I) subscale score (range, 0-10 points; higher scores indicate worse interference from pain; minimal clinically important difference, 1.0) at 12 months. RESULTS: Of 764 randomized patients (mean [SD] age, 60.5 [12.3] years; 66.5% were men), 632 (82.7%) completed 12-month follow-up. At 12 months, the whole health group had significantly improved pain interference scores (from 6.6 to 4.9) compared with the cognitive behavioral therapy (from 6.4 to 5.5) (mean difference, -0.58 [97% CI, -1.11 to -0.05]; P = .02) and usual care (from 6.4 to 5.7) (mean difference, -0.77 [99% CI, -1.40 to -0.15]; P = .002) groups. At 12 months, cognitive behavioral therapy did not improve pain interference scores significantly more than usual care (mean difference, -0.19 [99% CI, -0.89 to 0.50]; P = .46). The most common adverse event was suicidal ideation, which occurred in 15.9% of patients in the cognitive behavioral therapy group, 13.7% in the whole health team group, and 13.4% in the usual care group. CONCLUSIONS AND RELEVANCE: These results support use of the whole health team approach to attain a statistically significant but small improvement in pain interference in VA patients with chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04330365.

References

1. 1.Seal, K. H., Morasco, B. J., Martin, A. M., Reddy, K. P., Van Iseghem, T. M., Bolton, R. E., Bokhour, B. G., Murphy, J., Denneson, L. M., Esserman, D., Buta, E., Purcell, N., Bertenthal, D., Painter, J. T., Abadjian, L. R., Moore, L. C., Chan, A. C., McCamish, N., Maguen, S., Neylan, T. C., Gibson, C. J., & Becker, W. C. (2026). The Veterans Affairs' Whole Health Approach for Chronic Pain Management: The wHOPE Randomized Clinical Trial. JAMA. https://doi.org/10.1007/s11606-023-08376-0