PROJECT SUMMARY The COVID-19 pandemic has affected everyone in different ways. For people from the rural America with chronic diseases, particularly those who experience pain, the pandemic can not only worsen pain, but also it can trigger anxiety, depression, trouble sleeping, and substance use. This psychological distress is exacerbated by physical and social isolation, fear of seeking in-person visits, and diminished ability to access clinical care during the pandemic. One way doctors and health systems are reaching out is by video visits, where patients and their providers communicate online via the Internet. However, video visits still have limits. Therefore, we can help support them with other techniques. Beyond video visits, there are home-based programs that patients can administer themselves to help manage their pain. These proven programs can overcome staffing shortfalls, be used across long distance to reach anyone in the world and can be used at the time and place of the patients' choosing. In this study, we will compare two available, evidence-based, digital treatment programs that patients can use at home. The goal is to see if one approach is better than the other, and whether certain patients respond to one more than the other. The first program is an app that can run on any smartphone or computer. The program offers an 8-week, at-home curriculum to learn and practice new skills that can help manage pain. The program runs on a standard screen on your phone or computer. The second program is also a proven, 8-week program, but it uses a technology called virtual reality, or VR. VR involves wearing specialized goggles that create a sensation of being in a 3D world. Evidence shows that virtual worlds can help people learn and retain new skills that help reduce pain. The study will recruit 300 people from rural communities in California, Louisiana, and Alabama and randomize them into either the 2D or 3D programs. We will then follow patients for 8 weeks days and measure their pain levels. We will also measure signs of distress, including Coronavirus-related anxiety, along with measuring medications used for pain, such as opioids, and the impact of pain on overall quality of life. To conduct the study, we will ask patients to periodically complete short surveys online and allow permission for the research team to collect information from the electronic health record. We developed this study working with patient partners from the American Chronic Pain Association (ACPA), and they will be part of the research team throughout the conduct, analysis, and reporting of the study. The results will help patients, doctors, and health system decide how best to administer home-based, patient-administered, digital treatment programs for pain, and will offer recommendation on how to select the right treatment for the right patient.

PROJECT NARRATIVE The COVID-19 pandemic presents unique environmental, social, and physical barriers to patients with chronic pain in need of timely, high-quality healthcare. Evidence-based, on-demand, digital behavioral treatment programs that are entirely completed at home without clinician support can help bridge this gap, particularly for vulnerable patients in rural communities with limited access to mental health and pain care services. In this study, we will inform a key care delivery decision: which of two available, evidence-based digital treatments programs— a 2D mobile health application or a 3D virtual reality app—should health systems deploy to effectively deliver on-demand, home-based, digital therapy to address pandemic-related exacerbations of pain, stress, and anxiety among rural-dwelling Americans with chronic pain?