DeBar L, Mayhew M, Benes L, et al. A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial. Ann Intern Med. 2021 Nov 2. doi: 10.7326/M21-1436. (Original study)

BACKGROUND: Chronic pain is common, disabling, and costly. Few clinical trials have examined cognitive behavioral therapy (CBT) interventions embedded in primary care settings to improve chronic pain among those receiving long-term opioid therapy.

OBJECTIVE: To determine the effectiveness of a group-based CBT intervention for chronic pain.

DESIGN: Pragmatic, cluster randomized controlled trial. ( NCT02113592).

SETTING: Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest.

PARTICIPANTS: Adults (aged =18 years) with mixed chronic pain conditions receiving long-term opioid therapy.

INTERVENTION: A CBT intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorist, nurse, physical therapist, and pharmacist) versus usual care.

MEASUREMENTS: Self-reported pain impact (primary outcome, as measured by the PEGS scale [pain intensity and interference with enjoyment of life, general activity, and sleep]) was assessed quarterly over 12 months. Pain-related disability, satisfaction with care, and opioid and benzodiazepine use based on electronic health care data were secondary outcomes.

RESULTS: A total of 850 patients participated, representing 106 clusters of primary care providers (mean age, 60.3 years; 67.4% women); 816 (96.0%) completed follow-up assessments. Intervention patients sustained larger reductions on all self-reported outcomes from baseline to 12-month follow-up; the change in PEGS score was -0.434 point (95% CI, -0.690 to -0.178 point) for pain impact, and the change in pain-related disability was -0.060 point (CI, -0.084 to -0.035 point). At 6 months, intervention patients reported higher satisfaction with primary care (difference, 0.230 point [CI, 0.053 to 0.406 point]) and pain services (difference, 0.336 point [CI, 0.129 to 0.543 point]). Benzodiazepine use decreased more in the intervention group (absolute risk difference, -0.055 [CI, -0.099 to -0.011]), but opioid use did not differ significantly between groups.

LIMITATION: The inclusion of only patients with insurance in large integrated health care systems limited generalizability, and the clinical effect of change in scores is unclear.

CONCLUSION: Primary care-based CBT, using frontline clinicians, produced modest but sustained reductions in measures of pain and pain-related disability compared with usual care but did not reduce use of opioid medication.

PRIMARY FUNDING SOURCE: National Institutes of Health.

Discipline Area Score
Psychologist 7 / 7
Nurse 6 / 7
Physician 5 / 7
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Comments from MORE raters

Nurse rater

This is a very important topic. It's a good start in the many facets of chronic pain. The findings of sustained effects 12 mo. post treatment and no reduction in opioid use, makes this a good starting point for practice and future research. Embedding in primary care is an excellent opportunity to reduce "lost to follow-up". The CBT also has other useful uses in primary care.

Physician rater

The critical issue is that the intervention did not decrease opioid use; although, it had some improvement on pain.

Physician rater

It is remarkable how so many patients on chronic opioid use still can be found for chronic pain. The results are hardly or not clinically relevant and the CBT does not enable patients to stop (useless) opioid us.

Physician rater

This cluster controlled trial is larger than many involved in those investigating chronic pain. Therefore, its results are of more interest. The findings of the study, that there is reduced pain interference in patients receiving CBT is important; although, I note that there was a good deal of behavioural interventions in the CBT package that was given. Although the authors make it clear that the results may not be generalisable to a non-insured population, the findings are still important. I note that; although, benzodiazepine use reduced considerably, opioid use was not affected by the treatment package.

Psychologist rater

The reduction in pain and disability ratings among patients participating in CBT pain management groups was relatively small. However, of greater interest is that these effects were maintained over 12 months.

Psychologist rater

It's good to know that less intensive CBT programs (less than 100 hrs) can be useful for improving outcomes in pain management. This is useful for those conducting less intensive programs.

Psychologist rater

The generalizability of these findings to other settings and other approaches to providing CBT should be explored.
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