February 22, 2023

Study one of first to compare pain relief options for chronic low back pain patients already on opioids

man with low back pain

To help patients manage chronic, often debilitating pain, physicians frequently prescribe medications as first line therapy, although treatment guidelines often call for non-pharmacologic approaches.

One of the first studies to compare the effectiveness of the two approaches in low back pain patients already on long-term opioids has found that pain improvement was somewhat greater with nurse-delivered medication management than with psychologist-delivered cognitive behavioral therapy. Although the difference in pain relief was perceived as significant by patients, it was modest in magnitude. The researchers, from the U.S. Department of Veterans Affairs, Regenstrief Institute and Indiana University School of Medicine, noted a reduction in opioid use in participants in the medication management arm of the randomized clinical study.

“I think these findings that both optimized medication management — a pharmacologic approach — and cognitive behavioral therapy — a non-pharmacological approach — are beneficial, provide good news for patients and for clinicians,” said VA and Regenstrief Institute researcher Mathew Bair, M.D., M.S., who led the Care Management for the Effective Use of Opioids (CAMEO) study. “Also, hybrid care delivery — in person and via telephone — involving two-way communications between patients and clinicians — works well for a population that is very negatively impacted by their pain.”

Medication management was enhanced using a nurse care manager who interacted with the patients with chronic back pain, providing care guided by a specially designed algorithm which directed escalation of pain treatment from simple over-the-counter pain medications to more complex and different categories of pain medications, optimizing dose and patient response while minimizing side effects.

In the cognitive behavioral therapy arm of the study, patients were taught non-pharmacologic strategies and skills to help better cope with their pain and focus on capabilities, not disabilities. These efforts included establishing goals, managing flare ups, handling sleep challenges that are common in low back pain and improving communication with their clinicians.

Veterans with chronic low back pain for at least six months, for which opioids had been previously prescribed, were enrolled in the study. Individuals with active substance use disorder were excluded. Nine out of 10 of the 261 study participants were male.

Pain severity and pain interference with life activities were assessed at three, six, nine and 12 months of study participation.

Approximately half of all U.S. veterans live with chronic pain. Lower back pain is the most common type of pain in this population.

Many veterans who are prescribed opioids for chronic pain still have significant pain. They may also have PTSD (post-traumatic stress disorder), depression or other psychological conditions which can complicate treatment of their chronic pain,” said study co-author and Regenstrief Institute Research Scientist Kurt Kroenke, M.D. “Nurse care manager delivered optimized pain medication management, adding non-opioids to treatment regimens, should be just as effective or even more effective in the general population than in the veteran population for chronic low back pain and potentially for other chronic pain conditions.” Dr. Kroenke is a pioneer in the field of symptomology — the identification and treatment of medical symptoms.

Effect of Medication Optimization vs Cognitive Behavioral Therapy Among US Veterans With Chronic Low Back Pain Receiving Long-term Opioid Therapy: A Randomized Clinical Trial” is published in JAMA Network Open.

The study was supported by VA Health Services Research & Development and the National Institutes of Health’s National Center for Advancing Translational Sciences.

Building upon the CAMEO study, Dr. Bair is currently co-leading SCEPTER, a large comparative effectiveness study of low back pain in veterans, being conducted at 20 VA sites nationwide. The study is examining the effect on chronic low back pain of five non-pharmacologic treatments – physical therapy, internet-based pain self-management, yoga, cognitive behavioral therapy and spinal manipulation therapy. The VA-funded SCEPTER study is scheduled to be completed in 2026.

Study Author List

Michael A. Bushey, M.D., PhD (corresponding author)1; James E. Slaven, M.S.2; Samantha D. Outcalt, PhD3; Kurt Kroenke, M.D.4,5; Carol Kempf, R.N.3; Amanda Froman, B.S.3; Christy Sargent, B.S.3; Brad Baecher, MBA3; Alan J. Zillich, PharmD6; Teresa M. Damush, PhD3,4,5; Chandan Saha, PhD2; Dustin D. French, PhD7,8,9,10; Matthew J. Bair, M.D., M.S.3,4,5

Author Affiliations

1 Department of Psychiatry, Indiana University School of Medicine, Indianapolis

2 Department of Biostatistics and Heath Data Science, Indiana University School of Medicine, Indianapolis

3 Veterans Affairs (VA) Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana

4 Department of Medicine, Indiana University School of Medicine, Indianapolis

5 Regenstrief Institute, Inc, Indianapolis, Indiana

6 Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana

7 Department of Ophthalmology, Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois

8 Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois

9 Center for Health Services and Outcomes Research, Chicago, Illinois

10 Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois

Matthew J. Bair, M.D., M.S.

In addition to being a research scientist with Regenstrief Institute, Matthew J. Bair, M.D., M.S., is a core investigator at the Veterans Affairs Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center. He is a professor of medicine at Indiana University School of Medicine.

Kurt Kroenke, M.D. 
In addition to his role as a research scientist at Regenstrief Institute, Kurt Kroenke, M.D., MACP, is also a professor of medicine at Indiana University School of Medicine and a Chancellor’s Professor at IUPUI.

About Regenstrief Institute

Founded in 1969 in Indianapolis, the Regenstrief Institute is a local, national and global leader dedicated to a world where better information empowers people to end disease and realize true health. A key research partner to Indiana University, Regenstrief and its research scientists are responsible for a growing number of major healthcare innovations and studies. Examples range from the development of global health information technology standards that enable the use and interoperability of electronic health records to improving patient-physician communications, to creating models of care that inform practice and improve the lives of patients around the globe.

Sam Regenstrief, a nationally successful entrepreneur from Connersville, Indiana, founded the institute with the goal of making healthcare more efficient and accessible for everyone. His vision continues to guide the institute’s research mission.

About VA Health Services Research and Development Center for Health Information and Communication 

Located at the Richard L. Roudebush VA Medical Center, the Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) group is a diverse cadre of researchers collaborating to transform the healthcare system, both within and outside the VA so every patient receives consistent, high-quality care.

About IU School of Medicine

IU School of Medicine is the largest medical school in the U.S. and is annually ranked among the top medical schools in the nation by U.S. News & World Report. The school offers high-quality medical education, access to leading medical research and rich campus life in nine Indiana cities, including rural and urban locations consistently recognized for livability.

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