Background & Aims

Up to 60% of patients with advanced cancer and chronic pain experience inadequate relief from analgesics. Cognitive behavioral therapy for pain (pain-CBT) is the most widely utilized psychological treatment for chronic non-cancer pain, but requires adaptation for treatment of advanced cancer. MHealth interventions may overcome practical barriers that limit access to traditional behavioral therapies (e.g., travel time, insurance coverage, time spent in session) and allow delivery of in-the-moment, tailored intervention content, including advice and feedback during critical moments. To improve cancer pain outcomes, we sought to adapt and integrate pain-CBT into an existing mHealth intervention app designed to support advanced cancer patients using opioids to manage chronic pain. We conducted a single arm pilot study to evaluate the feasibility and acceptability of the pain-CBT app.

Methods

Patients recruited from the Stephenson Cancer Center (Oklahoma City, Oklahoma, USA) were ?21 years old, diagnosed with an advanced solid tumor or hematologic malignancy, had moderate-to-severe pain (>4/10) that was related to cancer/treatment, and were using opioids. Patients were excluded if they had a cognitive impairment, history of opioid use disorder, were enrolled in hospice, or had acute surgical pain. The app content integrated pain-CBT treatment with pain education and opioid support. The app delivered just-in-time adaptive interventions (e.g., algorithm-based advice for pain, stress, mood, and sleep management) in response to daily symptom surveys, and the app provided daily, multi-media psychoeducational content (e.g., 2D videos, behavioral games). Patients used the app for 4 weeks and completed both baseline and end of study surveys. Semi-structured debriefing interviews were optional. Feasibility was defined as >70% of patients being active on the app >50% of study days.

Results

Patients (n=19) completed a median of 71.4% of the 28 daily surveys, and 74% were active on >50% of days. Among patients who completed the end-of-study assessment, overall satisfaction with the app was good (median=4/5-pt Likert scale unless specified otherwise) with 75% reporting they would recommend it to a friend. Patients rated the app as understandable (median=4/5), easy to use (median=4/5), and helpful for learning about managing their pain (median 4/5). While underpowered to assess efficacy, pain severity and interference (Brief Pain Inventory-SF, baseline severity mean=4.71, interference mean= 5.89) decreased after 28 days of app use by 13% (severity) and 5% (interference). Pain catastrophizing scores also decreased slightly. Thematic analysis of interviews (n=12) suggested most patients felt the app improved their ability to self-manage cancer-related pain by facilitating effective pain management routines and providing insight on the relationship between mood and pain.

Conclusions

Current findings suggest that the STAMP+CBT app is an acceptable and feasible method to integrate and deliver psychological/behavioral treatment as an adjuvant to opioid therapy to foster pain self-management for patients with advanced cancer and pain. App engagement was high, and although engagement styles and intensity differed between users, post-study interviews clarified that most patients learned useful pain self-management skills. It may be that the dose (e.g., frequency and duration of engagement) required to promote learning of behavioral pain management skills differs per individual, supporting the case for a personalized approach to use technology-based pain management interventions. We will conduct a larger, randomized study to further evaluate feasibility and prepare for a fully powered efficacy trial.

References

Van den Beuken-van Everdingen MHJ et al. (2016) Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J Pain Symptom Manage.51(6):1070-90.e9.
Kwon JH (2014) Overcoming barriers in cancer pain management. J Clin Oncol.32(16):1727-33.
Deandrea S et al. (2008) Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol.19(12):1985-91.
Syrjala KL et al. (2014) Psychological and behavioral approaches to cancer pain management. J Clin Oncol.32(16):1703-11.
Gorin S et al. (2012) Meta-analysis of psychosocial interventions to reduce pain in patients with cancer. J Clin Oncol.30(5):539-47.
Somers TJ et al. (2016) A Small Randomized Controlled Pilot Trial Comparing Mobile and Traditional Pain Coping Skills Training Protocols for Cancer Patients with Pain. Pain Res Treat.2016:2473629.
Adam R et al. (2018) What are the current challenges of managing cancer pain and could digital technologies help? BMJ Support Palliat Care.8(2):204-12.

Presenting Author

Desiree R. Azizoddin

Poster Authors

Desiree Azizoddin

OTHR

Stephenson Cancer Center, University of Oklahoma Health Sciences Center

Lead Author

E-mail

Meng Chen

PhD

University of Oklahoma Health Sciences Center

Lead Author

E-mail

Sara DeForge

MA

University of Oklahoma Health Sciences Center

Lead Author

E-mail

Ashton Baltazar

MA

University of Oklahoma Health Sciences Center

Lead Author

E-mail

Robert Edwards

PhD

Brigham & Women's Hospital/Harvard Medical School

Lead Author

E-mail

Matthew Allsop

PhD

University of Leeds

Lead Author

E-mail

Michael Businelle

PhD

University of Oklahoma Health Sciences Center

Lead Author

E-mail

Kristin Schreiber

Brigham and Women's Hospital

Lead Author

E-mail

James A. Tulsky

Dana-Farber Cancer Institute

Lead Author

E-mail

Andrea Enzinger

Dana-Farber Cancer Institute

Lead Author

E-mail

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Cancer Pain & Palliative Care