The Reality of Modest Effectiveness
The other day I heard someone make the claim that psychological interventions for persistent, or chronic, pain are at best modestly effective. She went on to rhetorically ask why the field should promote such therapies when the empirical support for them is so unimpressive?
I’ve heard such statements countless times before.
It would be an important point if the field of pain management was filled with effective therapies. Pain management has many offerings in terms of therapies and procedures and, were it the case that these offerings were highly effective, it would make little sense to recommend behavioral therapies that are only modestly effective.
But it is not the case that there are many, highly effective therapies and procedures for the management of persistent pain. With one possible exception, there are actually no highly effective therapies for chronic pain.
Most often, opioids are thought to be powerful analgesics. This impression, however, doesn’t stand up to scientific scrutiny. The most recent meta-analysis on the effectiveness of opioids for chronic pain shows that they are better than placebo, but just a little bit more.1 The greater effectiveness of opioids amounts to less than 1-point greater reduction on the 0-to-10 rating scale. This study also looked at whether opioids were better at reducing pain than anti-inflammatory medications, tricyclic antidepressants, or anticonvulsants. The researchers found that they were all equally effective, which is to say, not very much more effective than a placebo.
Cannabis is a recent and increasingly common recommendation for the management of chronic pain. The most recent meta-analysis found that a “small to very small percentage” of people taking medical cannabis achieve 10% or more pain reduction.2 Again, these results show that cannabis is not very effective on average for the management of persistent pain.
Epidural steroid injections (ESI’s) are commonly recommended and performed for the management of chronic back and sciatic pain. The most recent meta-analysis showed that ESI’s reduced sciatic leg pain more than a placebo injection at 3-months following an injection, but not at 6 months following an injection. The difference in leg pain at 3-months between the real ESI and the placebo injection amounted to less than 1-point on a 0-to-10 pain rating scale. There was no difference between ESI’s and placebo injections for back pain at any of the follow-up periods.3 So, ESI’s are at best minimally effective.
Over recent years, spinal cord stimulators (SCS) have increasingly been utilized in pain management. However, they reduce pain by about 1-
point more than a placebo intervention on the 0-to-10 scale.4 Another recent study showed that SCS's are no more effective than a placebo intervention when it comes to reducing disability.5
Surgery for back pain is also commonly recommended and performed. The ICP recently performed a systematic review of meta-analyses for the various types of surgeries for back pain and showed that they too are at best minimally effective in much the same ways as ESI’s and SCS’s.
State of the art physical therapy combines physical therapy with pain education and the two are now commonly recommended and provided for those with persistent pain. The most recent meta-analysis shows that the combined therapies provide clinically large effect sizes in terms of reducing pain and disability at greater than 12 weeks.6 So, here is a therapy that most everyone would agree is effective.
Cognitive behavioral therapy (CBT) has long been recommended and provided to those with persistent pain. Most commonly provided by pain psychologists, CBT can be provided by any number of healthcare providers. Recent meta-analyses show, as we indicated above, modest effect sizes for those receiving surgery for low back pain7, chronic low back pain8,9 diabetic neuropathy,10 and fibromyalgia.11
Technically, for all these conditions, CBT showed modest effect sizes in its outcomes. However, these modest outcomes are superior to all other forms of treatment cited above with the exception of physical therapy. Physical therapy does show greater effectiveness than CBT, but both therapies have greater effectiveness than all other therapies and procedures.
The truth about the modest effectiveness of psychological interventions for the management of chronic pain is that it is pretty good when compared to all other therapies for chronic pain. True, cognitive-behavioral therapy for many chronic pain conditions is only modestly effective. However, most commonly performed therapies for chronic pain are not very effective at all. In comparison, CBT looks pretty good.
For more information, please see: Why Healthcare Providers Deliver Ineffective Care.
References
1. Busse, J. W., Wang, L., Kamaleldin, M… & Guyatt, G. H. (2018). Opioids for chronic noncancer pain: A systematic review and meta-analysis. JAMA, 320(23):2448-2460. doi: 10.1001/jama.2018.18472.
2. Wang, L., Hong, P. J., May, C… & Busse, J. W. (2021). Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: A systematic review and meta-analysis of randomized clinical trials. BMJ, 374. doi:10.1136/bmj.n1034
3. Verheijen, E. J. A., Bonke, C. A., Amorij, E. M. J., & Vleggeert-Lankamp, C. L. A. (2021). Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis. European Spine Journal, 30, 3255–3264. doi.org/10.1007/s00586-021-06854-9
4. Duarte, R. V., Nevitt, S., McNicol, E., Taylor, R. S., Buchser, E., North, R. B., & Eldabe, S. (2020). Systematic review and meta-analysis of placebo/sham controlled randomised trials of spinal cord stimulation for neuropathic pain. Pain,161(1), 24-35. doi: 10.1097/j.pain.0000000000001689
5. Hara S, Andresen H, Solheim O… & Gulati, S. (2022). Effect of spinal cord burst stimulation vs placebo stimulation on disability in patients with chronic radicular pain after lumbar spine surgery: A randomized clinical trial. JAMA,328(15):1506–1514. doi:10.1001/jama.2022.18231
6. Marris, D., Theophanous, K., Cabezon, P., Dunlap, Z., & Donaldson, M. (2021). The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: A systematic review and meta-analysis of randomized controlled trials. Physiotherapy Theory and Practice, 37(4), 461-472, doi: 10.1080/09593985.2019.1633714
7. Parrish, J.M., Jenkins, N.W., Parrish, M.S… & Singh, K. (2021). The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis. European Spine Journal, 30, 1365–1379. doi.org/10.1007/s00586-021-06747-x
8. Richmond, H., Hall, A. M., Copsey, B., Hansen, Z., Williamson, E… & Lamb, S. (2015) The effectiveness of cognitive behavioural treatment for non-specific low back pain: A systematic review and meta-analysis. Plos One, 10(8): e0134192. doi.org/10.1371/journal.pone.0134192
9. Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007). Meta-analysis of psychological interventions for chronic low back pain. Health Psychology, 26(1), 1–9. doi.org/10.1037/0278-6133.26.1.1
10. Bai, Y., Ma, J., Yu, Y., & Wang, Z. (2022). Effect of cognitive-behavioral therapy or mindfulness therapy on pain and quality of life in patients with diabetic neuropathy: A systematic review and meta-analysis. Pain Management Nursing, S1524-9042(22)00124-2. Advance online publication. doi.org/10.1016/j.pmn.2022.05.005
11. Bernardy, K., Klose, P., Welsch, P. & Häuser, W. (2018). Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome – A systematic review and meta-analysis of randomized controlled trials. European Journal of Pain, 22, 242-260. doi.org/10.1002/ejp.1121
Date of publication: 12-14-2022
Date of last modification: 12-14-2022
About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain. The Institute for Chronic Pain (ICP) provides academic quality information that is approachable to all. The goal of the ICP is to change the culture of how pain is managed, making it more effective and compassionate.