Although cognitive-behavioral therapy (CBT) is considered the gold-standard treatment for chronic pain, its real-world use is often limited by clinician shortages and the time demands of standard therapy.

Now, two new studies suggest that brief, virtual, and self-directed CBT approaches have the potential to overcome these barriers. Together, the findings indicate that shorter, more flexible interventions can significantly reduce pain interference while expanding the reach of effective, evidence-based pain care.

A randomized clinical trial published on June 24 in JAMA showed that self-directed CBT with asynchronous coaching led to greater reductions in pain interference than clinician-delivered therapy at 4 months among patients with chronic musculoskeletal pain, with benefits sustained through 12 months.

A second randomized clinical trial, published online on June 5 in PAIN, showed that six 30-minute brief CBT sessions led to significantly greater reductions in pain interference than usual care at 6, 12, and 24 weeks among primary care patients with chronic musculoskeletal pain. Clinically meaningful improvement was evident by mid-treatment and sustained through the 3-month follow-up.

“Many mental health providers already apply CBT techniques for conditions such as depression and anxiety…with some additional training and support, they can extend these foundational CBT skills to treat chronic pain successfully,” Gregory P. Beehler, PhD, MA, associate director for research at the Center for Integrated Healthcare in Buffalo, New York, and lead author of the PAIN study, told Medscape Medical News.

Effective, Underutilized

Chronic musculoskeletal pain is a common cause of disability and is typically associated with depression, sleep disturbance, reduced function, and high healthcare use. Although nonpharmacologic approaches are increasingly recommended in clinical guidelines, implementation remains inconsistent.

CBT is effective in improving pain-related outcomes, particularly pain interference, coping, and psychological distress. However, traditional CBT models that require 16 or more hours of treatment are often difficult to deliver in real-world settings, particularly in community-based care where shortages of trained therapists and long wait times are common. Insurance coverage and reimbursement limitations further restrict access in many health systems.

The JAMA trial evaluated whether a self-directed CBT program with personalized coaching could improve engagement and outcomes compared with clinician-delivered CBT under real-world practice conditions.

It included 764 US veterans (mean age, 52.8 years; 39.1% women; 54.0% White, 39.1% Black, and 14.0% Hispanic; 24% rural residents) with moderate-to-severe chronic musculoskeletal pain at nine Veterans Health Administration sites. Participants were randomly assigned to self-directed CBT with asynchronous personalized feedback or clinician-delivered CBT delivered under usual clinical practice conditions.

The self-directed intervention included 11 weeks of structured CBT supported by daily self-monitoring of pain-related behaviors, activity, and symptoms. Participants received weekly personalized audio feedback generated from these reports by trained coaches. The clinician-delivered comparator consisted of 4-11 weekly CBT sessions delivered in standard practice format.

At 4 months, self-directed CBT led to greater reductions in pain interference than clinician-delivered CBT (mean score, 5.26 vs 6.23), with benefits sustained through 6 and 12 months. Secondary outcomes, including pain intensity, catastrophizing, sleep, and depressive symptoms, also improved.

“We hypothesized that self-directed CBT would be superior because of its convenience, the consistency of its delivery, and the personalized coach support,” lead investigator Alicia Heapy, PhD, research psychologist at Veterans Affairs (VA) Connecticut Healthcare System in West Haven, Connecticut, and co-principal investigator Diana Higgins, PhD, clinical health psychologist at VA Connecticut Healthcare System, told Medscape Medical News in an email.

This provides an alternative way to access CBT for chronic pain in areas with little to no trained clinicians available. However, in the study, clinician-delivered CBT was effective, and some patients do prefer working one-on-one with a clinician, Heapy and Higgins added.

“Clinician-delivered CBT can be provided by local clinicians, and self-directed CBT can be delivered by clinicians at centralized hubs to patients across a healthcare system. This method would provide patients with more treatment options while improving access and treatment capacity across the system, especially in places with few trained clinicians,” they said.

Clinically Meaningful Outcomes

Unlike the JAMA trial, which compared self-directed with clinician-delivered CBT, the PAIN study evaluated whether a brief CBT program could improve pain outcomes when delivered in primary care. The trial enrolled 184 patients (mean age, 59 years; 84.8% men; 77.2% White) with moderate-to-severe chronic musculoskeletal pain at Veterans Health Administration primary care clinics who were randomly assigned to six 30-minute CBT sessions delivered over 12 weeks plus usual pain care or to usual pain care alone.

The manualized intervention included pain education, behavioral activation, relaxation training, cognitive restructuring, and relapse prevention and was delivered by integrated behavioral health clinicians.

Most participants experienced pain across multiple sites (mean, 3.7 pain locations), with back pain most frequently reported (83.7%). At baseline, 16.9% were prescribed opioids, and 36.1% had co-occurring depression.

Brief CBT resulted in greater reductions in pain interference than usual care at 6, 12, and 24 weeks, with improvements seen by mid-treatment and maintained through the 3-month follow-up with additional benefits in sleep and quality of life.

Clinically meaningful improvement was achieved by 6 weeks in the brief CBT group but not in usual care. By the end of the study, approximately half of the participants who received brief CBT achieved at least 30% improvement in pain interference.

“The rapid improvement we found challenges the notion that psychological treatment for pain is inherently intensive and therefore should be reserved for the most complex patients seen in specialty settings,” Beehler said.

“Our results suggest that, on average, even a small dose of focused treatment — three, 30-minute sessions — can potentially improve pain outcomes for patients,” he added.

A New Frontier for Chronic Pain Care

Although both studies evaluated different CBT delivery methods, they showed meaningful improvements in pain interference while significantly reducing treatment burden compared with traditional multisession therapy.

The findings are consistent with prior research showing that CBT can produce meaningful short- and long-term improvements even in patients with clinically significant pain burden, said Francis J. Keefe, PhD, professor of psychiatry and behavioral sciences at Duke University School of Medicine in Durham, North Carolina, who was not involved in either study.

He added that taken together the research supports a broader shift toward more flexible and scalable CBT delivery models for chronic pain.

“Many of the cutting-edge studies on CBT being conducted now are examining how to best personalize and tailor CBT to best meet the needs of the patient,” Keefe, who is also the director of the Duke Pain Prevention and Treatment Research Program, told Medscape Medical News. “This is quite important given how much heterogeneity there is in the large population of people suffering from chronic pain.”

Another pain expert, Beth Darnall, PhD, said expanding access to CBT remains a major focus of the field.

“Brief CBT and self-directed CBT with coaching support address key barriers because they are light touch (self-directed or brief), easier for patients to access and engage with, and therapists can treat more patients at once,” said Darnall, professor of anesthesiology, perioperative and pain medicine at Stanford University School of Medicine in Palo Alto, California, who also was not involved in either study.

Darnall, who also directs the Stanford Pain Relief Innovations Lab, said researchers are exploring other approaches to expand access to behavioral pain care, including text messaging support, virtual reality, and single-session interventions. “The overall trend is briefer, technology-assisted, and personalized feedback,” she said.

Lower-burden treatment options make it easier for patients to engage in care and could help reduce costs by reserving more intensive interventions for those who need them most while providing earlier treatment to reduce suffering and future healthcare use, Darnall said. “More efficient treatment options can scale access to entire populations of patients.”

Disclosure information for study authors is available in the original study’ publications. Darnall and Keefe reported no relevant financial disclosures.