Study Assesses Self-Management Intervention for Chronic Pain

BACKGROUND:
Chronic pain affects more adults in the U.S. than diabetes, heart disease, and cancer combined – and is associated with limitations in physical and emotional functioning, as well as quality of life. Cognitive behavioral therapy (CBT) is a low-risk psychological intervention that is effective in reducing pain and improving function for numerous pain complaints. Interactive voice response (IVR) – automated telephonic technology that allows patients to report symptoms, functioning, and pain coping skill use and to receive pre-recorded information and feedback – may improve access to CBT for chronic pain. This randomized trial assessed the efficacy of interactive voice response-based CBT (IVR-CBT) as compared to in-person CBT among 125 Veterans who received treatment for chronic back pain in the VA Connecticut Healthcare System from June 2012 through July 2015. IVR-CBT patients (n=62) received a self-help manual and weekly pre-recorded therapist feedback based on their IVR-reported activity, coping skill practice, and pain outcomes. In-person CBT patients (n=63) received weekly, individual CBT sessions with a therapist. Veterans in both groups received IVR monitoring of pain, sleep, activity levels, and pain coping skill practice during treatment. The primary outcome was change from baseline to 3 months in average pain intensity using a numeric rating scale (0=no pain, 10=worst pain imaginable). Secondary outcomes included changes in physical and emotional functioning, sleep, quality of life, adverse events, and treatment retention at 3, 6, and 9 months.

FINDINGS:

• Veterans in both the IVR-CBT and in-person CBT groups experienced statistically significant reductions in average pain intensity at 3 and 6 months post-baseline, but not at 9 months. Regarding secondary outcomes, Veterans in both groups experienced statistically significant improvements in physical functioning, sleep, and physical quality of life at 3 months relative to baseline, with no advantage for either group.
• The treatment dropout rate was lower among Veterans in the IVR-CBT group, with patients completing an average 2.3 more sessions.
• Forty-six Veterans experienced 92 related and unrelated adverse events (AE) (IVR-CBT=40; in-person CBT=52); all related AEs were minor with most related to increased pain from exercise.

IMPLICATIONS:

• IVR-CBT is a low-burden alternative that can increase access to CBT for patients with chronic pain; it also shows promise as a non-pharmacologic treatment option for chronic pain, with outcomes that are not inferior to in-person CBT.

LIMITATIONS:

• Because a third placebo arm was not included, investigators could not definitively show that either treatment is non-inferior to placebo.
• Veterans in this study were slightly older and had longer pain duration than participants enrolled in trials to establish the efficacy of CBT.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 09-058). Drs. Heapy and Goulet are part of HSR&D's Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center in West Haven, CT. Dr. Heapy is also with the Quality Enhancement Research Initiative (QUERI) Improving Pain-Related Outcomes for Veterans program.

Heapy A, Higgins D, Goulet J, et al. Interactive Voice Response-Based Self-management for Chronic Back Pain: The COPES Noninferiority Randomized Trial. JAMA Internal Medicine. April 3, 2017; Epub ahead of print.