Highlights
- •More disadvantaged patients benefited more from cognitive-behavioral therapy.
- •Patients with higher literacy benefited from both psychosocial treatments.
- •Patients with higher working memory benefited from both psychosocial treatments.
- •Patients with higher education benefited from both psychosocial treatments.
- •Simplifying cognitive-behavioral therapy reduces outcome disparities.
Abstract
Differences among patients can moderate the impact of evidence-based treatments (ie,
heterogeneity of treatment effects), leading patients to get more or less benefit.
The Learning About My Pain study was a randomized, comparative effectiveness trial
of a 10-week literacy-adapted group cognitive-behavioral therapy for chronic pain
(CBT) versus pain psychoeducation groups (EDU) versus usual medical care. We examined
potential sociodemographic and cognitive moderators of treatment effect among participants
with post-treatment assessments (N = 241). Analyses were conducted using moderation
in the PROCESS macro in SPSS and significant interactions were explored further. Education
and primary literacy moderated the difference between CBT and EDU on pain intensity,
and primary literacy, health literacy, and working memory moderated the difference
between CBT and EDU on pain interference. Analyses revealed few significant moderation
effects relative to usual medical care. No moderators were identified for depression.
Neither sex nor minority status moderated any differences between groups. Patients
with lower education, literacy, and working memory gained more benefit from CBT than
EDU. When provided sufficient guidance and structure in a way that is meaningfully
adapted, highly disadvantaged patients achieved as much benefit as less disadvantaged
patients, suggesting that the literacy-adapted CBT more successfully met the needs
of this population.
Trial registration
clinicaltrials.gov identifier NCT01967342
Perspective
This article presents findings related to heterogeneity of treatment effects for simplified
group psychosocial treatments for chronic pain. The results suggest that educationally,
cognitively, or literacy disadvantaged patients benefit most from the more structured
approach of literacy-adapted CBT rather than EDU, whereas less disadvantaged patients
benefit from either treatment.
Key words
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Article info
Publication history
Published online: April 22, 2019
Accepted:
April 16,
2019
Received in revised form:
March 16,
2019
Received:
October 7,
2018
Footnotes
Partially funded through a Patient-Centered Outcomes Research Institute® (PCORI®) Award (contract #941) and partially by the University of Alabama.
Disclosures: Dr. Van Dyke discloses financial support for conference registration and travel from the American Pain Society, the International Association for the Study of Pain, the University of Alabama, and Geisinger. Ms. Newman and Mrs. Moraís disclose financial support for conference registration and travel from the American Pain Society, the International Association for the Study of Pain, and the University of Alabama. Dr. Burns reports personal fees from the Patient-Centered Outcomes Research Institute. Dr. Thorn discloses book royalties from Guilford Publications, fees for consultation and training from the Pittsburgh Veteran's Administration, speaker's fees from Wellspan/Philhaven Health System, travel funds from Geisinger, and co-investigator and consultation fees from the National Institutes of Health. The authors do not have any other conflicts of interest to report.
Disclaimer: The statements presented in this article are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors, or Methodology Committee.
Supplementary data accompanying this article are available online at www.jpain.org and www.sciencedirect.com.
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© 2019 by the American Pain Society
