A new study by Thorn and colleagues, published in the Annals of Internal Medicine, finds the effects of cognitive behavioral therapy (CBT) and a pain education intervention (EDU) superior to standard treatment for the treatment of pain among low-income patients in community health centers in western Alabama. Additionally, their results suggest that the impact of modified, group-based EDU may be more enduring than the effects of an initially successful CBT intervention.
Thorn and team hypothesized that participants assigned to CBT and EDU conditions would experience gains beyond those experienced by patients exposed to usual treatment in the realms of pain intensity, physical function, and depression. Results supported these predictions in two of the three domains and implied lasting effects associated with EDU.
Chronic pain, defined by the authors as consistent pain exceeding a three- to six-month span, has implications that extend beyond suffering at an individual level. Pharmacological interventions are often employed to treat the experience of chronic pain, with 20% of physician visits and 10% of drug sales attributable to related symptoms. Rates of chronic pain are elevated within underserved communities, minority groups, and among women and older adults. Treatment represents an annual $600 billion industry in the United States alone.
“Recently published national clinical practice guidelines stress nonpharmacologic, evidence-based alternatives to pain medications. However, many providers are not familiar with such treatments as cognitive behavioral therapy (CBT), and access to CBT is limited, particularly in low-income communities.”
Issues of access, expense, and risks of side effects related to biomedical intervention and analgesic medications have set the stage for alternative approaches to pain relief. Particularly in light of the opioid crisis and other widespread challenges associated with addiction to pain medication, there is a need for affordable, thoughtful, evidence-based and reproducible interventions to support those suffering from chronic pain.
Chronic pain poses a financial burden on both individuals and larger systems. On an individual level, daily functioning, relationships with others, self-image, and professional responsibilities may be compromised by chronic pain, especially when pain is comorbid with psychological conditions. Economic and social inequalities create disparities in both in who experiences chronic pain and who receives alternative treatments.
Using a randomized controlled trial (RCT) design with two intervention conditions (CBT and EDU) compared to control (standard treatment), Thorp et al. collected data pre-intervention, mid-treatment, immediately following the ten-week intervention conditions, and six months post-intervention. Based on the concern that it would be difficult to track patients six months after the interventions had been complete, results hypothesized solely addressed immediate effects, although longer-term results were analyzed as well.
Primary-pain intensity (measured using the Brief Pain Inventory-Short Form Pain Intensity subscale), secondary-physical function (measured with the Brief Pain Inventory-Short Form Pain Interference subscale), and depression (measured with the Patient Health Questionnaire-9) were assessed to reflect effects. Sociodemographic data and pain management pattern data were also collected pre-intervention.
Participants in this study (N=290), adults ages 19-71, were randomly divided into one of two intervention groups or the control condition and were able to receive any usual medical care (medication, chiropractic or physical therapy, etc.) other than psychological treatment for the duration of the intervention. Pairs of therapists led both the CBT and EDU conditions, while standard treatment included usual clinic-provided care.
The CBT intervention took place in a group setting for 90 minutes each week for ten weeks total and involved simplified CBT techniques (i.e., motivational reinforcement, pain education, and pain management skills training). The EDU treatment occurred for 90 minutes each week across the same ten-week span, and both conditions were divided into small groups of seven to nine participants and were formatted similarly.
Results from linear mixed model analyses indicated larger decreases in pain intensity and improvements in physical function scores among members of the CBT and EDU groups than those who had received standard care. However, depression scores were not notably different between the CBT, EDU, and usual care groups. Upon six-month follow-up, post-treatment superiority to standard treatment was sustained for physical functioning, but pain intensity improvements among members of the EDU group outlasted those experienced by individuals in the CBT and usual care conditions.
“Focusing solely on a sample from a highly disadvantaged population, this trial demonstrates that literacy-adapted CBT and EDU are suitable adjunctive care options for adults with chronic pain attending low- income clinics. Given the extent of the adaptations made to the CBT intervention, our findings strongly suggest that CBT can be simplified to improve its accessibility while retaining its core principles and not reducing its potency.”
Barriers to access and inadvertent harm related to biomedical treatments for chronic pain serve to hinder already vulnerable populations in the process of seeking support. Although Thorn and colleagues conducted their research only in clinics in a single US state (compromising generalizability), the power and strength of effects detected in the current study suggest great potential for pain education programming and CBT in alleviating chronic pain across diverse medical conditions.
Thorn, B. E., Eyer, J. C., Dyke, B. P., Torres, C. A., Burns, J. W., Kim, M., . . . Tucker, D. H. (2018). Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics. Annals of Internal Medicine. (Link)