Tweaking Therapy for Disadvantaged Patients Improves Chronic Pain

TUSCALOOSA, Ala. — Adapting cognitive behavioral therapy and group pain education for disadvantaged patients improved their chronic pain, according to a study led by psychologists at The University of Alabama.

It is the first rigorous trial to test if cognitive behavioral therapy is effective for patients of low socioeconomic status.

Held at community health clinics serving low-income patients in mostly rural areas of Alabama, the study set out to find if simplifying cognitive behavioral therapy, or CBT, and group pain education, shortened as EDU, for patients with low reading skills would help them to manage their pain more effectively.

The 290 people in the study reported large reductions in pain intensity with an increase in physical function and lower depression after participating in the modified CBT or pain education groups, according to the results published in the Annals of Internal Medicine. More importantly, the participants had better outcomes in pain intensity reductions and increases in physical function than usual medical care for chronic pain, according to the study.

“This trial demonstrates that literacy-adapted and simplified group psychosocial treatments, cognitive-behavioral therapy and biopsychosocial pain education, are suitable as adjunctive care options for adults with chronic pain attending low–income clinics,” said Dr. Beverly E. Thorn, emerita professor of psychology at UA who remains an active researcher and adviser for graduate students. “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.”

The patient outcomes are further evidence that CBT and EDU should be integrated into chronic pain management programs to help the patient remain as functional as possible with as little medication as possible, she said.

New treatment guidelines by the Veteran’s Administration, Center for Disease Control and the College of Physicians and Surgeons recommend doctors and caregivers consider other treatment options for chronic pain before prescribing medications, particularly addictive opiates.

“It’s already established that CBT helps people with chronic pain,” Thorn said. “There certainly is a place for medication for chronic and acute pain, but we have gone overboard in offering addictive medications as the first line of options.”

More than 116 million Americans have chronic pain, costing $600 billion annually, and chronic pain is estimated to be the reason for one in five physician visits and 10 percent of drug sales. Chronic pain disproportionately affects economically disadvantaged persons, ethnic minority groups, women and older adults who have higher rates of chronic pain, greater risk for pain-related disability, and higher rates of major chronic physical and psychological comorbid conditions, according to previous research.

Often, those who suffer from chronic pain, particularly racial minorities, are seen as potential abusers or sellers of opioid pain medications, Thorn said. In fact, when the study began, some in the medical community told Thorn she would not find patients to participate because the study did not offer drugs, she said.

“The 290 patients who participated in our most recent study did so because they were sick of the way the meds made them feel. They were sick of being looked at as ‘drug seekers,’ and they said the meds didn’t help eradicate the pain in any case, so why keep taking them?” Thorn said. “The people showed up, knowing I was not offering drugs, but the possibility of learning how to better manage their pain.”

Thorn is the lead author of the paper published Feb. 27 and includes co-authors from UA, Rush University Medical Center, Ohio State University, East Carolina University, University of California Los Angeles, University of Alabama at Birmingham and Virginia Commonwealth University along with Integrated Psychology Solutions in Little Rock, Arkansas; Arizona Emergency Medicine Research Center in Tucson, Arizona; Whatley Health Services in Tuscaloosa; Pacific Rehabilitation Centers in Bellevue Washington; and CHI Franciscan Medical Group in Tacoma, Washington.

The study was funded by a research award from the Patient-Centered Outcomes Research Institute and UA.