BETHESDA, MD -- Evidence-based nonpharmacologic therapies may be at least as effective as medications in treating chronic pain, and the Internet could prove to be a valuable method for delivering these interventions.
Although pharmacologic agents alone are of only modest benefit and rarely lead to clinically meaningful functional improvement among patients with chronic pain, there is strong evidence for nonpharmacologic therapies such as cognitive-behavioral therapy in improving functional status and mood, as well as pain itself, David A. Williams, Ph.D., said at the meeting, sponsored by the University of Michigan and the National Institutes of Health.
A meta-analysis of 25 papers found that active psychological treatments based on the principle of cognitive-behavioral therapy (CBT) produced significantly greater improvements in pain experience, cognitive coping, appraisal, and behavioral expressions of pain, compared with other active treatments, in patients with a variety of chronic pain problems, excluding headache (Pain 1999;80:1-13).
Another meta-analysis, involving 22 studies of adults with noncancerous chronic low back pain, found that psychological interventions--particularly CBT and self-regulatory treatments--significantly reduced pain intensity, pain-related interference, and depression while significantly improving health-related quality of life. Multidisciplinary approaches that included psychological interventions also had positive effects (Health Psychology 2007;26:1-9).
Two more meta-analyses--one of 49 studies, the other of 23--have demonstrated an equal or greater effect for nonpharmacologic therapies compared with pharmacologic treatment for fibromyalgia (Ann. Behav. Med.l999;21:180-91; Pain 2010;151:280-95).
"There is a 30-year history of nonpharmacologic interventions that have rival effect sizes to some pharmacologic approaches and even surpass some. The problem is, (nonpharmacologic interventions are] rarely used in clinical practice," said Dr. Williams, professor of anesthesiology, medicine (rheumatology), psychiatry, and psychology and associate director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.
The use of nonpharmacologic treatment has been limited for various reasons. Medical schools don't spend much time teaching it, insurance companies often don't adequately cover it, patients often can't access it, it lacks the million-dollar marketing campaigns that pharmaceutical companies devote to their drugs, and it carries a stigma, he noted.
Delivering such evidence-based interventions via the Internet potentially sidesteps several of the barriers that prevent their wider use. Numerous pilot or small-scale studies have supported the efficacy and utility of this approach, with outcomes that are often consistent with or even greater than those identified when using traditional face-to-face modalities, Dr. Williams said.
The following are studies of Web-based interventions with evidence to support their efficacy. Some of the sites are now online, others were developed in the context of academic research and are currently not available to the public:
* E-mail discussion groups. These early e-health efforts demonstrated significant benefit in a randomized controlled trial of 580 individuals with chronic low back pain, from 49 states. The intervention included a moderated e-mail discussion group combined with a workbook and videotape about back pain. Controls received a subscription to a nonhealth magazine of their choice. At 1 year, the e-mail group had significant improvements in pain, disability, role function, distress, and health care use (Arch. Intern. Med. 2002;162:792-6).
* Swedish study. In this controlled trial, 56 patients with chronic low back pain were randomized to 8 weeks of Internet-based CBT with telephone support or a waiting list. Treatment included CBT modules on relaxation, exercise and stretching, cognitive restructuring, activity pacing, and relapse prevention. …