1. The cooperative pain education and self-management (COPES) study was a randomized, non-inferiority trial that demonstrated similar efficacy in improvement of chronic back pain with cognitive behavioral therapy (CBT) administered by interactive voice response (IVR) telephone software compared to in-person therapy.
2. The IVR-CBT group had significantly improved adherence to therapy than those in the in-person CBT arm.
Evidence Rating Level: 2 (Good)
Study Rundown: Chronic pain is one of the leading causes of major disability and is associated with increased reliance on opioid therapy despite poor outcomes. Recommended management includes a multi-modal approach that can involve cognitive behavioral therapy (CBT), an intervention with evidence-based benefit in a variety of pain disorders. Need for trained administrators and resources often limit the use of CBT, especially outside of academic and urban centers. This study evaluated the use of automated telephone interactive voice response-based CBT therapy compared to traditional CBT in patients with chronic back pain in a randomized, non-inferiority trial.
The trial demonstrated that both strategies reduced numerical ratings of pain at three months of follow-up without any significant differences between the two strategies. There were also similar improvements in physical functioning, sleep quality, and quality of life in both groups. The IVR-CBT group had better adherence to therapy with greater number of therapy sessions completed. The main strength of the study was in its comparison to well established standard of care CBT rather than to prior baseline or placebo. The exclusion of large numbers of patients due to concomitant substance use or psychiatric comorbidity limited its generalizability to a real-world setting.
In-Depth [randomized controlled trial]: This study was a randomized, non-inferiority trial comparing IVR- and in-person CBT in a population from a single VA health care system. Electronic health records were screened for chronic back pain of at least 4/10 severity over the prior three months and ability to walk. Patients were excluded if they planned on surgical intervention, had significant medical or psychiatric comorbidity, had substance use disorder, psychosis, or dementia. In-person CBT sessions consisted of 30-40 minutes with a therapist every week, while IVR patients received personalized feedback once per week.
Overall, 125 patients were randomized from 508 initially evaluated, and patients were balanced with respect to known age, race, and baseline pain characteristics. At three months of follow-up the IVR-CBT group had reduction in numeric pain scale of -0.77, while in-person CBT had a change of -0.84 with no significant difference (95%CI for difference -0.67 to 0.80). More participants in the IVR group completed at least 3 sessions (56 vs. 46, p = 0.02), and the IVR group completed more sessions overall (mean 8.9 vs. 6.6, p < 0.001). Both groups had improvements in physical functioning, sleep quality, and quality of life without differences between the two arms.
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