simplified group education & cognitive-behavioral therapy ... · annual meeting oct. 31-nov. 2,...

ANNUALMEETING

OCT. 31-NOV. 2, 2017ARLINGTON, VA

#PCORI2017

Simplified Group Education & Cognitive-Behavioral Therapy for Chronic Pain: No Prescription Required

Beverly E. Thorn, Ph.D., ABPP Professor EmeritaThe University of AlabamaNovember 1, 2017

ANNUAL MEETING | #PCORI2017

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[Note to speaker: Please use only one of the next two slides depending on your disclosure information. ]

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• Has nothing to disclose.

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What is Chronic Pain?

• Pain lasting more than 3-6 months• Pain that has persisted beyond the time of healing. • Pain without apparent biological value• Non-malignant pain (excludes cancer pain)

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Chronic Pain Impacts Well-Being and Function

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Recent Shifts in Treatment Guidelines for Pain Management• Recognize opioid epidemic• Discourage medication as first-line treatment• Encourage pain self-management training

• Include patient education about chronic pain• Include cognitive-behavioral therapy

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Study Objectives

• Can we simplify pain self-management treatments, and are they effective?

• Do simplified group treatments for pain (Pain Education, Cognitive-Behavioral Therapy) reduce self-reported pain intensity and interference in physical functioning over and above that provided by usual medical care, and are these effects maintained at 6-months follow-up?

• Is Cognitive-Behavioral Therapy more effective than Pain Education (especially for reducing depression)?

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What is Pain Education (EDU)?

• Comes in many forms, but in this study:• Group treatment – 6-8 people, 10 weekly 90-min. session• Based on biopsychosocial model (acknowledges biological,

but emphasizes psychological and social influences)• Focused on:

• Information regarding pain – emphasized how the brain processes pain

• Information on pain self-management• Interactive discussion forum

• Did not provide skills training

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What is Cognitive-Behavioral Therapy (CBT)?• Comes in many forms, but in this study:

• Group treatment – 6-8 people, 10 weekly 90-min sessions• Based on biopsychosocial model (acknowledges biological,

but emphasizes psychological and social influences)• Focused on:

• Self-management skills training• Stress reduction skills (e.g., relaxation)• Thoughts management skills• Emotion management skills• Activity pacing skills

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But…..These Treatments Can Be Difficult To Grasp• Requires the patient to read and write• Requires homework and worksheets• Requires some level of abstract thinking• May require above average cognitive functioning• Sometimes limited to high-functioning individuals

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Simplifying These Treatments Is Crucial For Disadvantaged Patients

• Education• Primary literacy & health literacy• Minority Status• Stress of poverty• Underserved

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Did We Simplify Our Treatments?• Simplified patient materials:

• Reduced reading level of text• Reduced amount of text• Added illustrations• Increased font size• Increased white space

• Reduced cognitive demand of treatment: • Limited the number of concepts per session• Simplified oral presentation of concepts (no jargon)• Collaborative learning via heavy use of flip chart-facilitated discussions• Did not require homework• Gave out weekly CDs with session summaries

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Illustrations Enhanced the Meaning of the Text…

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Reducing Disparities with Literacy-Adapted Psychosocial Treatments for Chronic Pain: A Comparative Trial

PCORI Contract #941• 5/15/13-7/31/17

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Comparative Effectiveness Trial

• 3 Conditions:• Cognitive-Behavioral Therapy (n=95)• Pain Education (n=97)• Medical Treatment as Usual (n=98)

• 83% retained at primary endpoint (post-tx)• CBT (87%)• EDU (84%)• TAU (80%)

• 75% retained at 6 mo. follow-up

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Baseline Characteristics of Study Participants by Treatment GroupNo. (%)

All (n=290) TAU (n=98) CBT (n=95) EDU (n=97)Age, mean (SD) 50.6 (8.9) 49.7 (8.7) 52.2 (8.5) 49.9 (9.2)

Women 205 (70.7) 69 (70.4) 67 (70.5) 69 (71.1)Race

White/Caucasian 96 (33.1) 38 (38.8) 20 (21.1) 38 (39.2)Black/African-American 194 (66.9) 60 (61.2) 75 (78.9) 59 (60.8)

Marital StatusSingle 71 (24.5) 27 (27.6) 24 (25.3) 20 (20.6)Married or in a relationship for > 2 yrs

100 (34.5) 36 (36.7) 27 (28.4) 37 (38.1)

Divorced, Separated, Widowed

119 (41.0) 35 (35.7) 44 (46.3) 40 (41.2)

Poverty StatusBelow poverty status 210 (72.4) 74 (75.5) 65 (68.4) 71 (73.2)Above poverty status 70 (24.1) 20 (20.4) 25 (26.3) 25 (25.8)

Does Simplified CBT Work??Yes

• CBT & EDU, pre-post, and at 6 mos. (not TAU)

• Moderate Effect sizes• CBT may have a small

advantage:• Larger effects sizes• More Clinically Meaningful

Improvements (post & 6 mo)

• But EDU is a viable alternative for low-resourced clinics

Finding Good Pain Treatment is Hard. If You’re Not White, It’s Even Harder (NYT, August, 2016)

• Ms. Lewis, the former dollar store employee, said the best balm for her pain had been 10 weeks of group cognitive behavioral therapy, which aims to help people change how they think about pain.

• “I learned so much I was actually shocked,” Ms. Lewis said of her cognitive behavioral therapy.

• “It’s about triggering your brain to go to something else, other than the pain.”

https://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in-patients-pain-treatment.html?_r=0

https://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in-patients-pain-treatment.html?_r=0


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Learn More

• www.pcori.org

• [email protected]

• #PCORI2017

• Pmt.ua.edu

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Questions?

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Thank You!Beverly E Thorn, Ph.D., ABPP

Professor Emerita, The University of Alabama

11/1/2017

simplified group education & cognitive-behavioral therapy ... · annual meeting oct. 31-nov. 2,...

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