NEW YORK (Reuters Health) – Simplifying cognitive behavioral therapy (CBT) and an educational intervention (EDU) by adapting them to patients’ literacy levels improves chronic pain and function in low-income individuals compared with usual care, researchers say.
“Focusing solely on a highly disadvantaged sample – low income, low reading skills – this trial demonstrates that literacy-adapted and simplified group psychosocial treatments are suitable as adjunctive care options for adults with chronic pain attending low-income clinics,” Dr. Beverly Thorn of the University of Alabama in Tuscaloosa told Reuters Health by email.
For the study, Dr. Thorn and colleagues randomized 290 participants (mean age, 51; 70.7% women; 66.9% minority group members; 72.4% at or below the poverty level; and 35.8% reading below the fifth-grade reading level) to CBT, EDU or usual care. In all, 241 (83.1%) completed post-treatment assessments.
The primary pain site was the lower back for roughly half of the participants.
CBT and EDU were delivered in 10 weekly 90-minute group sessions, with all information and materials modified to be accessible to patients reading at or below the fifth-grade level. Usual care consisted of intermittent phone contact to facilitate retention, but no psychosocial treatment.
As reported online February 26 in Annals of Internal Medicine, patients in the CBT and EDU groups had larger decreases in pain intensity scores between baseline and post-treatment assessment than those receiving usual care. Estimated differences in change scores compared to usual care were -0.80 for CBT and -0.57 for EDU. At six-month follow-up, overall pain-related treatment gains had not been maintained in the CBT group but were still present in the EDU group.
The proportions of participants specifically with 30% or greater improvement in pain intensity score at post-treatment were 30.5% for CBT, 20.0% for EDU, and 11.5% for usual care; at six-month follow-up, the proportions were 21.7%, 16.4%, and 8.5%, respectively.
The CBT and EDU groups also had greater improvements in physical function scores than those receiving usual care. The proportions of participants who had improved by at least 30% post-treatment were 40.2% for CBT, 28.8% for EDU, and 18.4% for usual care; at six-month follow-up, the proportions were 34.8%, 20.6%, and 15.7%, respectively.
Changes in depression did not differ among the groups.
Dr. Thorn said, “Given the extent of the adaptations made to CBT, our findings strongly suggest that CBT can be simplified to improve its accessibility, while retaining its core principles and without reducing its potency.”
“Serious issues regarding implementation remain,” she said, “because staff time and funding for training of appropriate healthcare providers is typically not a high priority in healthcare systems whose activities are guided by a pay-for-service model.”
“Further, remuneration for staff time involved in providing the treatments is typically not reimbursed by third-party payers,” she added. “Moreover, until these types of treatments are integrated into a comprehensive on-site treatment plan for patients with chronic pain, they will be considered ‘alternative’ and thus looked upon as ‘less than’ by patients and physicians alike.”
Dr. Robert Kerns of Yale University in New Haven, author of a related editorial, said the study “provides compelling evidence that even the most disadvantaged among us – those living in rural settings with low educational attainment, low literacy, underemployment, low wealth, high rates of mental health and substance use disorders, and minority race – can benefit from psychological approaches that promote adaptive pain self-management when efforts are made to adapt the approach to take these vulnerabilities into account.”
“Although not specifically examined, it is likely that such approaches can have additional benefit in reducing reliance on opioid therapy and mitigating the associated risk of harms,” he said in an email to Reuters Health.
“Evidence of the effectiveness of this treatment approach for chronic pain encourages confidence that similar adaptations of existing evidence-based psychological approaches could benefit those with other medical and mental health conditions . . . such as diabetes, cardiovascular disease, obesity, depression and anxiety disorders,” he added.
“Unfortunately,” Dr. Kerns said, “despite the individual and public health benefits, organizational, provider and patient barriers to accessing this and similarly effective approaches remain challenging.”
Like Dr. Thorn, he said, “Perhaps most important is that these approaches are often not reimbursed by Medicare and Medicaid or other health insurance entities.”
“The lack of adequate financial incentives for delivery of these approaches stands in contrast to generally available compensation for more expensive and risky interventions with less evidence of effectiveness for acute and chronic pain,” he concluded, “such as injections, implantable devices and surgery.”
SOURCES: http://bit.ly/2FxUL4W and http://bit.ly/2FxUMpw
Ann Intern Med 2018.
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