CBT, education both effective for sickle cell pain management
Therapy, coaching seen as low-cost, quality approaches to care
Cognitive behavioral therapy (CBT) and pain education, each delivered using digital mobile systems and supported by a peer health coach, were equally effective at lessening the impact of sickle cell disease (SCD) pain, a study found.
The U.S.-based clinical trial, CaRISMA (NCT04419168), involved more than 300 adults with SCD. Results were reported in the study, “Digital Cognitive Behavioral Therapy vs Education for Pain in Adults with Sickle Cell Disease,” published in Blood Advances.
The researchers highlighted the impact of peer health coaches in enhancing the effectiveness of digital therapeutics, finding that CBT selectively improved patients’ ability to manage the day-to-day mental, emotional, and medical aspects of SCD.
People with SCD often experience painful vaso-occlusive crises (VOCs), when sickle-shaped red blood cells get stuck inside blood vessels and block blood flow. VOC-related pain is most commonly felt in the hands, feet, joints, chest, or back and can last anywhere from a few days to a few weeks.
Such pain burden can lead to distress, extreme stress, and anxiety, making it challenging to manage daily life.
Sickle cell pain management alternatives
Managing pain may require treatment with medication like opioids “that have limited long-term efficacy data and known adverse effects,” the researchers wrote, adding that “effective non-pharmacologic pain treatments are needed.”
CBT is a type of psychotherapy that helps people recognize and change negative thought patterns and behaviors. It’s been shown to be effective in treating several pain conditions by helping individuals develop coping strategies and more adaptive ways of managing their pain.
Its use in SCD has been limited, with reported barriers including “limited availability or access, cost, and stigma related to seeking mental health services,” the researchers wrote. “Mobile health interventions could expand access to CBT and improve health outcomes.”
With this in mind, a team led by researchers at the University of Pittsburgh launched the CaRISMA trial to compare the efficacy of digital CBT and digital pain/SCD education for reducing pain in adults with SCD.
A total of 359 adults with SCD-associated chronic pain were recruited at seven centers from August 2020 to December 2022. Their mean age was 36.3. Nearly all (92.5%) were Black, and 66.3% were women.
Participants were randomly assigned to participate in either digital CBT or digital education. Those who underwent CBT were taught how to recognize negative thoughts and emotions and use problem-solving to apply coping strategies. They also had access to a study-associated Facebook page for support.
The educational intervention focused on pain and SCD education, with an emphasis on teaching about chronic pain, the biology of SCD pain, and healthy lifestyle tips.
“Both interventions were co-created with and tailored for adults with SCD, providing scripted chat interactions and video lessons,” the team wrote. Both groups had access to trained health coaches, mostly SCD patients or caregivers, who offered weekly support for the first three months.
Participants completed online tests at several timepoints, as well as daily pain diaries.
The study’s primary goal was to evaluate changes in pain interference, as assessed by the PROMIS Pain Interference (PROMIS-8a), which measures pain’s impact on social, physical, cognitive, emotional, and recreational activities.
Secondary goals included changes in patient-reported assessments of pain intensity, emotional impact, depression, anxiety, quality of life, and self-efficacy.
Six-month results
The researchers reported six-month results showing that both interventions led to significant reductions in pain interference relative to study’s start. However, no significant changes were detected in daily pain intensity.
Patients also showed significant reductions in terms of depression, anxiety, and emotional impact, as well as significant improvements in social functioning.
CBT alone resulted in significant improvements in self-efficacy, or the ability to manage SCD day to day. That suggests the therapy may influence the treatment mechanism, “potentially contributing to positive outcomes if engagement is optimized,” the team wrote.
When comparing the two approaches, the researchers found no significant differences in terms of PROMIS-8a score changes, suggesting similar effectiveness in terms of pain interference.
Similarly, there were no significant differences between the groups’ effects on daily pain intensity, depression, anxiety, social functioning, or self-efficacy. Group differences in terms of changes in emotional impact approached significance, with CBT associated with greater improvements.
Most participants (79.7%) completed at least one health coach session, most of which were done by telephone and lasted a mean of 25 minutes.
A similar proportion of participants in each group never connected to the chatbot (24% vs. 23%), with reported reasons including “not wanting to be on Facebook, difficulty with passwords, and lack of reminders,” the researchers wrote.
“Variable engagement with digital components and high engagement with health coaching may explain the lack of between-group differences,” they wrote.
The findings show that “digital CBT, or pain education, when combined with centralized health coach support, may serve as a scalable and low-cost method for delivering high-quality behavioral care to underserved communities, addressing the challenges of chronic pain and mental health in SCD and other marginalized populations,” the team concluded.
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