CBT intervention reduced pain and disability but not opioid use in patients with chronic pain

For long-term opioid users with chronic pain, a cognitive behavioral therapy (CBT) intervention that included yoga and education was associated with reductions in pain and pain-related disability compared with usual care, a randomized controlled trial found.

Researchers conducted the Pain Program for Active Coping and Training study among adults with mixed chronic pain conditions receiving long-term opioid therapy at Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest U.S. They randomly assigned clusters of primary care clinicians to implement the CBT intervention, which involved an interdisciplinary team (behaviorist, nurse, physical therapist, and pharmacist) teaching pain self-management skills and a yoga-based adapted movement approach in 12 weekly, 90-minute groups, or to continue usual care with unrestricted pharmacologic and nonpharmacologic treatments. The trial's primary outcome was patient-reported pain impact at 12 months, as measured by the four-item Pain, Enjoyment of Life, and General Activity (PEG) scale (range, 0 to 10; higher score indicates worse impact). Secondary outcomes were pain-related disability, satisfaction with care, and opioid and benzodiazepine use. Participants were assessed at baseline and at three, six, nine, and 12 months. Results were published Nov. 2 by Annals of Internal Medicine.

A total of 850 participants (mean age, 60.3 years; 67.4% women) were included, representing 106 clusters of primary care clinicians. Of these, 96.0% completed follow-up assessments. Compared to patients who received usual care, those in the intervention group had larger reductions in all self-reported outcomes from baseline to 12 months, with changes in PEG score of −0.434 point (95% CI, −0.690 to −0.178 point) for pain impact and −0.060 point (95% CI, −0.084 to −0.035 point) for pain-related disability. At six months, patients in the intervention group reported higher satisfaction with primary care (difference, 0.230 point [95% CI, 0.053 to 0.406 point]) and pain services (difference, 0.336 point [95% CI, 0.129 to 0.543 point]). Opioid use did not differ significantly between groups; however, benzodiazepine use decreased more in the intervention group (absolute risk difference, −0.055 [95% CI, −0.099 to −0.011]).

Among other limitations, all participants were insured and were receiving care in a large, integrated health care system, which limits the generalizability of the findings, the study authors noted. They added that while they had aimed to enroll patients prioritized by the health system due to high doses of opioids, concurrent benzodiazepine receipt, or high health care use, only a modest proportion met those criteria.

“Despite limitations, this study shows the potential for skill-based, CBT interventions delivered by frontline clinicians to reduce pain impact and improve function among patients with chronic pain receiving long-term opioid treatment. Although effects were modest, they persisted after treatment through final 12-month followup,” the authors concluded. “Given the limited efficacy and safety of long-term opioid treatment of chronic pain and increasing demand for nonpharmacologic treatment, this type of intervention may be an attractive option.”