Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial.

Background: Chronic pain is common and challenging to treat. Although cognitive behavioral therapy (CBT) is efficacious, its benefit in disadvantaged populations is largely unknown. Objective: To evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT01967342). Setting: Community health centers serving low-income patients in Alabama. Patients: Adults (aged 19 to 71 years) with mixed chronic pain. Interventions: CBT and EDU delivered in 10 weekly 90-minute group sessions. Measurements: Self-reported, postintervention pain intensity (primary outcome) and physical function and depression (secondary outcomes). Results: 290 participants were enrolled (70.7% of whom were women, 66.9% minority group members, 72.4% at or below the poverty level, and 35.8% reading below the fifth grade level); 241 (83.1%) participated in posttreatment assessments. Linear mixed models included all randomly assigned participants. Members of the CBT and EDU groups had larger decreases in pain intensity scores between baseline and posttreatment than participants receiving usual care (estimated differences in change scores-CBT: -0.80 [95% CI -1.48 to -0.11]; P = 0.022; EDU: -0.57 [CI, -1.04 to -0.10]; P = 0.018). At 6-month follow-up, treatment gains were not maintained in the CBT group but were still present in the EDU group. With regard to physical function, participants in the CBT and EDU interventions had greater posttreatment improvement than those receiving usual care, and this progress was maintained at 6-month follow-up. Changes in depression (secondary outcome) did not differ between either the CBT or EDU group and the usual care group. Limitations: Participants represented a single health care system. Self-selection bias may have been present. Conclusion: Simplified group CBT and EDU interventions delivered at low-income clinics significantly improved pain and physical function compared with usual care. Primary Funding Source: Patient-Centered Outcomes Research Institute.

An Examination of Cultural Values and Pain Management in Foreign-Born Spanish-Speaking Hispanics Seeking Care at a Federally Qualified Health Center.

OBJECTIVE: Most studies done with Hispanics illustrate their preference for self-management practices; therefore, examining the factors driving patients to seek medical care for pain management will help elucidate what patients want and need from their doctors for pain management. The aim of the present study was to obtain patients' perspectives and enhance our understanding of the cultural beliefs influencing pain management decisions of foreign-born Spanish-speaking Hispanics with low acculturation. METHODS: Twenty-four individuals (17 females and 7 males) with self-reported chronic pain completed the study. Participants attended a focus group and shared about pain management practices and their experiences with medical care for pain management. Descriptive data on pain and mood variables were collected to examine how this population compares with the norms reported in the pain literature for Hispanics. RESULTS: Participants reported a preference for pain self-management and noninvasive medical treatments and expressed negative attitudes toward pain medications, although wanting the option of pain medications as a "last resort." Satisfaction with medical care for pain was highly influenced by the participants' expectations and preference for personal, warm, and friendly interactions. CONCLUSIONS: Our findings are consistent with previous reports on Hispanics' preference for self-care practices. Perhaps foreign-born Hispanics may rely on self-care practices and delay medical attention for pain management because of their unfamiliarity with the US health care system. Other potential explanations for a reliance on self-care for pain management involve patients having a limited understanding of or access to effective treatment options for chronic pain and negative experiences with US medical providers.

Future implications of eHealth interventions for chronic pain management in underserved populations.

Many underserved communities, especially those in rural settings, face unique challenges that make high quality healthcare less accessible. The implementation of eHealth technologies has become a potentially valuable option to disseminate interventions. The authors' work in rural Alabama Federally Qualified Health Centers provide insights into the access to technology as well as the likelihood of utilizing eHealth technology in underserved communities. This paper will review current challenges related to digital dissemination of behavioral health interventions for chronic pain. Two major concerns are the lack of technological resources and the lack of appropriate materials for patients who may have low levels of reading, health and/or digital literacy. We will propose some recommendations to address common barriers faced by those providing care.