Behavioral Intervention Eases Chronic Pain for Dialysis Patients

A cognitive behavioral intervention eased chronic pain for people with kidney failure on maintenance hemodialysis, a randomized clinical trial found.

After 12 weeks, pain coping skills training (PCST) reduced the interference of pain on activities of daily life compared with usual care, with a between-group difference of -0.49 points on the 10-point Brief Pain Inventory (BPI) scale (95% CI -0.85 to -0.12, P=0.009), reported Laura Dember, MD, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues.

This effect persisted through week 24 (between-group difference -0.48, 95% CI -0.86 to -0.11). By week 36, 12 weeks after the training ended, the difference in pain interference scores was no longer better than usual care (between-group difference -0.34, 95% CI -0.72 to 0.04).

“The effect on the overall cohort was modest, but the intervention produced a clinically important change for a substantial proportion of participants,” the researchers wrote in JAMA Internal Medicine. The between-group difference of about 0.5 points fell short of the 1-point minimal clinically important difference, they said.

But they pointed out that a greater proportion of participants in the intervention group compared with the usual care group had a greater than 1-point reduction in the BPI Interference score — an absolute difference of 14% and relative difference of 39%, with a number needed to treat of seven — which suggests the training still had a “meaningful” effect.

By week 12, 50.9% of the PCST group achieved over a 1-point decrease in BPI Interference score compared with 36.6% in the usual care group (OR 1.79, 95% CI 1.28-2.49). By week 24, 55% and 42.8% of the PCST and usual care groups achieved greater than 1-point decrease in pain score (OR 1.59, 95% CI 1.13-2.24).

“Very few interventions have been shown to improve the quality of life for people with end-stage kidney disease being treated with dialysis,” commented Paul Kimmel, MD, of the National Institute of Diabetes and Digestive and Kidney Diseases, which funded the study, in a statement. “For example, opioids, which have been a main treatment for pain in this population, have side effects that can be more pronounced in the presence of kidney failure, making pain management challenging.”

Kimmel’s group had previously found that dialysis patients had 4% higher 2-year mortality with short-term opioid prescriptions and 27% higher risk with longer-term opioid scripts, as well as increased risks of dialysis discontinuation and hospitalization.

The acceptability, tolerability, and safety of the cognitive behavioral therapy intervention make the results “particularly compelling,” Dember and colleagues noted.

“Nonpharmacologic approaches are appealing given the high burden of medications required for this patient population,” they wrote. “The absence of adverse effects attributable to PCST contrasts favorably with pharmacologic pain interventions.”

As part of the HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis study, 643 participants were randomized: 319 to PCST and 324 to usual care. Participants were randomized from 16 U.S. academic centers and 103 outpatient dialysis facilities from January 2021 to April 2023. Average age was 60.3 years, 44.8% were female, 47.9% were Black patients, 18.5% were Hispanic or Latino, and 32.7% were white.

At baseline, all had in-center maintenance hemodialysis for at least 90 days and self-reported moderate or severe chronic pain, defined as pain on most days or every day during the past 3 months and a score of 4 or higher on a scale of 0 to 10 on the Pain, Enjoyment of Life, and General Activity scale.

As part of the PCST, patients had weekly coach-led sessions lasting 45 to 50 minutes via video or telephone conferencing for 12 weeks, followed by an additional 12 weeks of automated interactive voice response sessions. Content for the program was adapted to include modules addressing pain-related anxiety, stress, and sleep difficulties.

Dialysis patients who participated in PCST also had greater improvements in a few secondary outcomes compared with usual care by week 24:

• Pain intensity, with a between-group mean difference of -0.50 points (95% CI −0.85 to −0.16) on the 10-point BPI Severity scale
• Catastrophizing, with a -1.49-point difference (95% CI -2.46 to -0.52) on the 24-point Pain Catastrophizing Scale six-item short form scale
• Depression, with a difference of -0.94 points (95% CI -1.82 to -0.06) on the nine-item Patient Health Questionnaire, which has a range from 0 to 27
• Anxiety, with a -0.98-point (95% CI -1.84 to -0.13) difference on the seven-item Generalized Anxiety Disorder scale (range 0-21)

The PCST group also had greater improvements on the single-item quality of life scale, though the between-group difference didn’t reach statistical significance.

One limitation of the study was a lack of a cost-effectiveness analysis, so conclusions couldn’t be made about the economic implications of adopting the PCST intervention.

“Future work will focus on how to prolong the favorable effects of pain coping skills training and how to broadly implement this intervention in clinical practice,” Dember said in a statement.

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