Primary Care CBT Offers Modest Relief for Chronic Pain

Primary care-based cognitive behavioral therapy (CBT), including a yoga practice, led to moderate but durable reductions in pain measures in individuals with chronic pain but did not pare down the use of opioids, researchers reported.

In an adult population with mixed chronic pain conditions who were on long-term opioid therapy, those who participated in the intervention saw larger reductions on multiple self-reported outcomes from baseline to follow-up, specifically:

• 12-month follow-up change in pain intensity and interference with enjoyment of life, general activity, and sleep scale (PEGS): −0.434 point for pain impact (95% CI −0.690 to −0.178 point).
• 12-month follow-up change on the Roland Morris Disability Questionnaire (RMDQ): −0.060 point for pain-related disability (95% CI −0.084 to −0.035 point).
• 6-month change in satisfaction with primary care: 0.230-point difference (95 CI 0.053 to 0.406 point).
• 6-month change in satisfaction with pain services: 0.336-point difference (95% CI 0.129 to 0.543 point).

However, there were no intervention-related differences in average daily opioid dose per morphine milligram equivalents (MME) at the post-treatment assessment (−2.260 points difference, 95% CI −5.509 to ₋0.989 points) or at 12 months (−1.969 points difference, 95% CI −6.765 to 2.827 points), according to Lynn DeBar, PhD, MPH, of Kaiser Permanente (KP) Washington Health Research Institute in Seattle, and co-authors.

While benzodiazepine use did drop with the intervention, the effect was “inconsistent,” according to the authors, as there were greater reductions at 12 months versus usual care participants for an absolute risk difference of −0.055 (95% CI −0.099 to −0.011), but this benefit did not hold up at post-treatment assessment (ARR −0.026, 95% CI −0.065 to −0.012).

The latter finding may have been influenced by the fact that they “sought to enroll patients prioritized by the health system due to high doses of opioids, concurrent benzodiazepine receipt, or high health care use, [and] only a modest proportion met these criteria” the authors wrote in the Annals of Internal Medicine.

But what the intervention lacked in “wow factor” it made up for by offering evidence for “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… 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,” DeBar’s group noted.

The pragmatic, cluster randomized PPACT study was done at the three KP healthcare regions of Georgia, Hawaii, and in the Northwest U.S. Primary care (PC) clinics from the three regions were invited to participate in the study from 2014 through 2016. DeBar and co-authors described the recruitment methods and study protocol in 2018 in Contemporary Clinical Trials. They cautioned that the 4-week window in which PC physicians (PCP) could direct patients to the study—as dictated by the cluster randomized design—”may have inadvertently eliminated patients who were initially hesitant about behavior-based treatments.”

The CBT intervention taught pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team of a behaviorist, nurse, physical therapist (PT), and pharmacist. The intervention was compared with usual care, which consisted of PCPs providing pharmacologic and nonpharmacologic treatments to their patients without restriction, the authors explained.

The “adapted movement” aspect of the intervention included “yoga-based movement (stretching and strengthening),” using a DVD program based on findings from the Yoga of Awareness trials. The yoga was guided by the PT, and offered “a gentle yoga practice tailored to encourage patients to participate daily in gentle and accessible movements with the intention that these skills will begin to generalize to everyday activities requiring physical movement. In-session, yoga-based adapted movement is limited to seated and supported standing poses because the degree of deconditioning expected for this target population suggests that these practices are best suited to their current functional limitations,” DeBar’s group wrote.

In total, 850 patients (mean age 60.3; 67.4% women; 76.6% White) participated and represented 106 PCP clusters. Participants mean BMI was 32.8 kg/m², and 44% had any mental health diagnosis. Also, almost half had hypertension, while <10% had current or historical misuse of alcohol or drugs. The median average daily dose of opioids was 29.6 MME. Of the 850 patients, 96% completed follow-up.

In terms of adverse events, none were deemed related to the intervention, with a dozen deaths and 287 hospitalizations, although fewer intervention participants landed in-hospital versus usual care (116 versus 171).

The authors acknowledged that PPACT participants were older with a slightly higher disease burden than those in other studies looking at CBT, but that the intervention was similar in intensity to previous trials, such as a 2018 study that looked at literacy-adapted CBT versus education for chronic back pain, and a 2017 study of opioid taper support.

DeBar’s group explained that the “magnitude of our intervention effects was also similar to that in trials of yoga for low back pain, which is relevant given the yoga-based exercise component of our intervention,” referring to a systematic review by the Agency for Healthcare Research and Quality that was updated in 2020.

Study limitations included the fact that all the participants were insured and treated at a large, integrated healthcare system, which limited generalizability. Also, the study goal of detecting “small effect sizes rather than minimal clinically important differences across study groups,” according to the authors.

One of the major champions of the use of yoga and other non-drug measures to manage chronic pain is M. Catherine Bushnell, PhD, scientific director of the Division of Intramural Research at the NIH National Center for Complementary and Integrative Health (NCCIH).

Bushnell discussed her group’s research at a 2013 NCCIH lecture, explaining that “[healthy] yoga practitioners had more gray matter in key brain areas versus health controls.” She also pointed out that “[yoga]-related changes in insula [cortex] are more important for higher pain tolerance in yoga practitioners.” Other data from India and U.K. also supported yoga for dealing with chronic pain and low back pain, respectively.

“The research we’ve done shows that an individual, through his or her own means, can learn to engage the same networks in the brain that are engaged when taking a pain medication,” Bushnell said in a 2019 NIH “I Am Intramural” blog. “Yoga is one of the ways a person can do this because it engages the parts of the brain that are important in dampening pain. This is done through the physical exercise, meditation, and breath control that yoga requires, which lead to the activation of areas of the brain which dampen pain, all without taking drugs.”

As for potential boons of yoga for managing addiction and substance abuse disorders (SUD), a 2018 narrative review by Arpit Parmar, DM, of the All India Institute of Medical Sciences in New Delhi, and co-authors wrote that “yoga and related therapies appear to be an effective tool, especially in case of nicotine-use disorders.” However, they noted that the majority of the studies reviewed, including using yoga for abuse of alcohol, opioids, and cocaine, “reported favorable short-term outcomes…[and]…are to be interpreted with caution considering the use of indirect measures such as QoL [quality of life], score on depression rating scale, and markers of stress.”

An NCCIH health information page also stresses that “preliminary results have been positive, larger, high-quality studies are needed to determine if yoga is an effective treatment” for SUDs.

In an interesting side note, a 2018 documentary on BKS Iyengar, considered one of the “founding fathers” of modern yoga, featured Joseph Pereira, a Catholic priest in Mumbai, India who runs the Kripa Foundation where yoga is used to treat SUDs. The foundation “aims to change the addict’s lifestyle through a holistic approach. That’s where yoga comes in,” Pereira told Indian Catholic Matters.

1. A skill-based, cognitive behavioral therapy (CBT) intervention delivered by primary care physicians reduced pain and improved function among patients with chronic pain receiving long-term opioid treatment.

2. The CBT intervention, which included a yoga component, did not significantly impact opioid use.

Shalmali Pal, Contributing Writer, BreakingMED™

Cat ID: 438

Topic ID: 437,438,438,730,192,46,48,922