Collaborative care medication optimization more effective than CBT in reducing pain

Optimizing collaborative care medication was modestly more effective than cognitive behavioral therapy in reducing pain impact among United States veterans, researchers reported in JAMA Network Open.

Medication management and cognitive behavioral therapy (CBT) are commonly used treatments for chronic low back pain. However, there is a lack of evidence available comparing their effectiveness, Michael A. Bushey, MD, PhD, assistant professor of psychiatry at Indiana University, and colleagues wrote.

Bushey and colleagues aimed to compare collaborative care medication optimization with CBT on pain intensity, interference and other pain-related outcomes.

The authors used the Care Management for the Effective Use of Opioids trial, a 12-month randomized clinical trial, to recruit U.S. veterans aged 18 years and older. Trial participants were veterans with chronic lower back pain who were prescribed long-term opioids at seven Veterans Affairs clinics.

A total of 261 patients (92.3% male; mean age, 57.9 years) were randomized and included in the study. Participants were randomized to receive either collaborative care with nurse care manager-delivered medication optimization (n = 131) or psychologist-delivered CBT (n = 130) for 6 months, with follow-up visits after 9 and 12 months.

The primary outcome was assessed through change in Brief Pain Inventory (BPI) score at 6 and 12 months. Scores on the BPI range from 0 to 10, with higher scores representing greater pain impact. A 30% improvement was considered clinically meaningful.

Baseline mean scores were 6.45 for the collaborative care group and 6.49 for the CBT group.

Improvements in BPI scores were “significantly greater” in the collaborative care group after 12 months (between-group difference, –0.54; 95% CI, –1.18 to –0.31), the researchers wrote, although they were not significantly greater after 6 months (difference, –0.46; 95% CI, –0.94 to 0.11).

“Our results indicate that a collaborative care medication optimization approach has a statistically significant but clinically modest benefit when compared with CBT for 12 months,” Bushey and colleagues wrote. “This finding suggests that both pharmacological and behavioral approaches are reasonable options for chronic pain.”