Behavioral therapy eases chronic pain in disadvantaged populations

Beverly E. Thorn

Interventions involving literacy-adapted and simplified group cognitive behavioral therapy and pain education significantly improved pain and physical function in patients presenting at low-income clinics, according to findings published in Annals of Internal Medicine.

“Research has already shown that CBT (and some types of pain education) are effective for reducing pain, and increasing function in people with chronic pain,” Beverly E. Thorn, PhD, from the University of Alabama, told Healio Internal Medicine. “However, it is unknown whether it could be simplified and used with a very disadvantaged population (over 70% at or below poverty level, and over 35% reading below the fifth-grade reading level) to help them with pain self-management.”

Thorn and colleagues conducted a randomized controlled trial to investigate the efficacy of literacy-adapted and simplified group CBT for treating chronic pain in a disadvantaged population, compared with group pain education and usual care. The researchers enrolled 290 adults aged between 19 and 71 years with mixed chronic pain from community health centers serving low-income patients in Alabama.

A total of 70.7% of participants were women, 66.9% were minority group members, 72.4% were at or below the poverty level and 35.8% were reading below a fifth-grade level. Participants were randomly assigned to receive CBT (n = 95), group pain education (n = 97) or usual care (n = 98). The interventions were delivered in 10 weekly 90-minute group sessions.

Participants in the CBT group were taught techniques involving motivational reinforcement, pain education and pain management skills. Those receiving group pain education were provided information on pain self-management. Usual care included receipt of any nonpsychological pain management method such as medication, chiropractic or physical therapy.

The researchers found that reductions in pain intensity scores between baseline and posttreatment were greater in participants receiving CBT and group pain education than those receiving usual care (estimated differences in change scores for CBT = – 0.8; 95% CI –0.48 to –0.11; group pain education = –0.57; 95% CI, –1.04 to –0.1). Treatment gains were maintained in the group pain education intervention after 6 months, but not in the CBT intervention.

Compared with participants receiving usual care, posttreatment improvement was greater in those receiving CBT and group pain education was maintained at 6-month follow-up. There was no difference between any of the groups in changes in depression.

“Clinicians should partner with behavioral health providers, such as clinical health psychologists, or get appropriate training themselves to conduct these group interventions at their treatment site as part of their comprehensive treatment plan for their patients with chronic pain,” Thorn said. “Providers can help patients come to an understanding that pain self-management skills training is part of the overall treatment rather than referred out as an ‘extra’ for only some people for whom biomedical treatment doesn’t work. This integration of treatment would go a long way in helping patients accept the treatment and would likely help avoid some common medication management issues.”

The next step is moving into a phase of treatment efficacy research that focuses on treatment mechanisms because it is clear that CBT and other types of pain education are effective, she said.

According to Thorn, questions that need to be answered include: “What patient factors predict positive treatment response, and how can we best tailor our treatments to minimize patient vulnerabilities and maximize patient strengths? And what is the ‘secret sauce’ in the approach that is driving the beneficial response? Is the key to treatment success being able to change patients’ catastrophic thought processes? Is the key getting them to engage in physical activities? Is the key helping them to feel self-empowered?”

“These are all possible treatment mechanisms and we need much more research into these processes so that we can target them specifically in our treatments,” she said.

In an accompanying editorial, Robert D. Kerns, PhD, from Yale University, wrote that the study by Thorn and colleagues is important as it addresses and offers a model for assessing and treating pain in disadvantaged populations.

“Many challenges remain, especially the need to realign financial incentives to encourage health care organizations and providers to invest in evidence-based, noninvasive, nonpharmacologic approaches to chronic pain management, including psychological therapies,” he wrote. “The time is ripe for a national transformation in pain care, including explicit attention to disparities.” – by Alaina Tedesco

Disclosure: Thorn reports receiving grants from PCORI, indirect cost recovery for research expenses from the University of Alabama and personal fees from Guilford Publications. Please see study for all other authors’ relevant financial disclosures. Kerns reports no relevant financial disclosures.

Beverly E. Thorn

Interventions involving literacy-adapted and simplified group cognitive behavioral therapy and pain education significantly improved pain and physical function in patients presenting at low-income clinics, according to findings published in Annals of Internal Medicine.

“Research has already shown that CBT (and some types of pain education) are effective for reducing pain, and increasing function in people with chronic pain,” Beverly E. Thorn, PhD, from the University of Alabama, told Healio Internal Medicine. “However, it is unknown whether it could be simplified and used with a very disadvantaged population (over 70% at or below poverty level, and over 35% reading below the fifth-grade reading level) to help them with pain self-management.”

Thorn and colleagues conducted a randomized controlled trial to investigate the efficacy of literacy-adapted and simplified group CBT for treating chronic pain in a disadvantaged population, compared with group pain education and usual care. The researchers enrolled 290 adults aged between 19 and 71 years with mixed chronic pain from community health centers serving low-income patients in Alabama.

A total of 70.7% of participants were women, 66.9% were minority group members, 72.4% were at or below the poverty level and 35.8% were reading below a fifth-grade level. Participants were randomly assigned to receive CBT (n = 95), group pain education (n = 97) or usual care (n = 98). The interventions were delivered in 10 weekly 90-minute group sessions.

Participants in the CBT group were taught techniques involving motivational reinforcement, pain education and pain management skills. Those receiving group pain education were provided information on pain self-management. Usual care included receipt of any nonpsychological pain management method such as medication, chiropractic or physical therapy.

The researchers found that reductions in pain intensity scores between baseline and posttreatment were greater in participants receiving CBT and group pain education than those receiving usual care (estimated differences in change scores for CBT = – 0.8; 95% CI –0.48 to –0.11; group pain education = –0.57; 95% CI, –1.04 to –0.1). Treatment gains were maintained in the group pain education intervention after 6 months, but not in the CBT intervention.

Compared with participants receiving usual care, posttreatment improvement was greater in those receiving CBT and group pain education was maintained at 6-month follow-up. There was no difference between any of the groups in changes in depression.

“Clinicians should partner with behavioral health providers, such as clinical health psychologists, or get appropriate training themselves to conduct these group interventions at their treatment site as part of their comprehensive treatment plan for their patients with chronic pain,” Thorn said. “Providers can help patients come to an understanding that pain self-management skills training is part of the overall treatment rather than referred out as an ‘extra’ for only some people for whom biomedical treatment doesn’t work. This integration of treatment would go a long way in helping patients accept the treatment and would likely help avoid some common medication management issues.”

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The next step is moving into a phase of treatment efficacy research that focuses on treatment mechanisms because it is clear that CBT and other types of pain education are effective, she said.

According to Thorn, questions that need to be answered include: “What patient factors predict positive treatment response, and how can we best tailor our treatments to minimize patient vulnerabilities and maximize patient strengths? And what is the ‘secret sauce’ in the approach that is driving the beneficial response? Is the key to treatment success being able to change patients’ catastrophic thought processes? Is the key getting them to engage in physical activities? Is the key helping them to feel self-empowered?”

“These are all possible treatment mechanisms and we need much more research into these processes so that we can target them specifically in our treatments,” she said.

In an accompanying editorial, Robert D. Kerns, PhD, from Yale University, wrote that the study by Thorn and colleagues is important as it addresses and offers a model for assessing and treating pain in disadvantaged populations.

“Many challenges remain, especially the need to realign financial incentives to encourage health care organizations and providers to invest in evidence-based, noninvasive, nonpharmacologic approaches to chronic pain management, including psychological therapies,” he wrote. “The time is ripe for a national transformation in pain care, including explicit attention to disparities.” – by Alaina Tedesco

Disclosure: Thorn reports receiving grants from PCORI, indirect cost recovery for research expenses from the University of Alabama and personal fees from Guilford Publications. Please see study for all other authors’ relevant financial disclosures. Kerns reports no relevant financial disclosures.