FROM JAMA

Adults suffering from chronic lower back pain may be better off pursuing mindfulness-based stress reduction or cognitive behavioral therapy rather than more standard, conventional treatments for pain alleviation, according to a new study published in JAMA.

However, the relatively limited availability of cognitive and mindfulness-based approaches to stress reduction in many parts of the country, coupled with the uncertainty about insurance providers covering such treatments, put the viability of such treatments receiving widespread acceptance and use in question.

“Low back pain is a leading cause of disability in the United States, [and] psychosocial factors play important roles in pain and associated physical and psychosocial disability,” said Daniel C. Cherkin, Ph.D. , of the Group Health Research Institute in Seattle, and his associates. “Cognitive behavioral therapy [CBT] has demonstrated effectiveness for various chronic pain conditions and is widely recommended for patients with chronic low back pain, [but] patient access to CBT is limited.”

Dr. Cherkin and his coinvestigators recruited subjects from Group Health, an integrated health care system in Washington state, looking for patients between the ages of 20 years and 70 years with low back pain persisting for at least 3 months that was both nonspecific and had not been given a specific diagnosis ( JAMA. 2016 Mar;315[12]:1240-9 ).

Of 1,767 patients evaluated, 342 patients were enrolled and randomized into one of three cohorts: those receiving mindfulness-based stress reduction (MBSR) (116 patients), those receiving CBT (113 patients), and those receiving “usual care,” defined as “whatever care participants received” prior to enrollment (113 patients).

Those randomized to receive usual care received $50 toward whichever pain management option they chose to receive. Those receiving MBSR or CBT were not aware of which they were receiving until they attended the first group session.

A total of 8 sessions, each 2 hours long and offered weekly, were conducted for patients in each cohort, although attendance at each session was not mandatory. Follow-up with patients in each cohort was conducted at 4 weeks (halfway through treatment), 8 weeks (post-treatment), 26 weeks (primary endpoint of the study), and 52 weeks, with the number of patients in each cohort varying at each follow-up; patients who attended follow-up interviews were compensated $20.

Improvements in functional limitations of at least 30% and intensity of back pain were the primary outcomes measured. The former was measured via a modified Roland Disability Questionnaire (RDQ), which assessed patients’ physical limitations brought on by low back pain on a scale of 0-23, with 0 being the least intense and 23 being the most intense. The latter outcome was measured on a simple scale of 0-10, 0 being the least intense and 10 being the most intense.

At 26 weeks, RDQ scores for MBSR and CBT patients were significantly higher than for those patients receiving usual-care treatment options. Mean percentage improvement in the MBSR cohort was 60.5% and 57.7% in the CBT cohort. Comparatively, patients receiving usual care improved by an average of 44.1% (P = .04). MBSR showed the highest percentage improvement at all four follow-up intervals except 8 weeks, when CBT had a higher percentage. However, both were consistently higher than usual care throughout.

When it came to the second primary outcome, MBSR and CBT were again shown to be significantly more effective, registering mean percentage improvements of 43.6% and 44.9% at 26-week follow-up, respectively. The usual care cohort, on the other hand, improved by 26.6% (P = .01).

Regarding study limitations, Dr. Cherkin and his coinvestigators noted that “participants were enrolled in a single health care system and generally highly educated. [Also] the generalizability of findings to other settings and populations is unknown, [and] approximately 20% of participants randomized to the MBSR and CBT groups were lost to follow-up.”

The pressing question, however, is the viability of MBSR and CBT therapies, particularly the former. While treatments such as yoga and meditation are relatively widespread throughout the United States, getting insurance providers to cover such treatments may be a roadblock for doctors looking to prescribe such therapies to their chronic back pain patients.

Because CBT and MBSR have been around for more than 30 years, they are accessible mostly in urban areas of the country, usually through programs run by hospitals, and “reaches [that] are more open to the idea of mindfulness and meditation concepts,” Dr. Cherkin explained in an interview. However, he added, “they are not generally covered [by] insurance, but we’re hoping that studies like ours will help change that.”

The problem, said Dr. Cherkin, is the allocation of resources by insurance and health care providers to certain treatment and therapies that aren’t necessarily the most effective.

“Just because something isn’t covered by insurance doesn’t mean it isn’t helpful and cost effective,” he explained. “And on the opposite side, many things that are covered by insurance are not very helpful.”

Dr. Cherkin cautioned that, while the findings of this study are promising – especially as they relate to the growing desire by both providers and patients to turn away from opioids for chronic pain management – these findings are ultimately just one step along a longer journey.

“Opioids are often resorted to out of desperation by both physicians and patients who both feel there isn’t any alternative, and physicians don’t like to see their patients continuing to suffer,” said Dr. Cherkin. “Things have gotten way out of whack over the years, because there has not been an evidence-based approach to ensuring that what is most helpful for patients is available and offered by insurance.

“If we can look at the most effective treatment options available to patients that have low risks of addiction, death, or other harm and make those available so physicians can include those in their repertoire of what they feel they can offer patients, we’re going to be in much better shape,” Dr. Cherkin noted.

The National Center for Complementary and Integrative Health funded the study. The authors did not report any relevant financial disclosures.

dchitnis@frontlinemedcom.com

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