EMOTIONAL AWARENESS AND EXPRESSION THERAPY OR COGNITIVE BEHAVIOR THERAPY FOR THE TREATMENT OF CHRONIC MUSCULOSKELETAL PAIN IN OLDER VETERANS: A PILOT RANDOMIZED CLINICAL TRIAL

Abstract

Introduction Chronic pain affects as many as 80% of older veterans and is one of the mostly costly disorders treated in Veterans Affairs (VA) settings. Both the CDC and VA recently recommended psychosocial treatments as first-line treatments for chronic pain, along with non-opioid pharmacologic options. Yet standard psychosocial treatment options currently implemented in VA, such as Cognitive Behavioral Therapy (CBT), have only modest benefits for a minority of patients. In contrast, a novel manualized psychotherapy approach with a heretofore underutilized mechanism, Emotional Awareness and Expression Therapy (EAET), has shown medium-to-large effect size benefits for some patients, which may indicate promise for helping older patients avoid riskier treatment options such as opioid analgesics and invasive procedures for their pain. Methods This study is a pilot randomized (1:1) clinical trial (RCT) comparing two group psychotherapy treatment conditions (EAET and CBT) for chronic musculoskeletal pain in Veterans age 50 years and older, currently underway (target N=64). The main objectives of this pilot were to assess the acceptability and feasibility of the treatments, and to provide limited-efficacy testing and obtain an estimated effect size for power calculations for a subsequent larger RCT. Patients received one 90-minute individual session and eight 90-minute group psychotherapy sessions according to the condition to which they were randomly assigned. EAET sessions were conducted by either the study principal investigator or a psychology intern, and CBT sessions were conducted by an experienced psychologist and a geriatric psychology fellow. Demographics (age, gender, years of education) and clinical variables (number of medications, number of medical conditions, presence of opioids) were collected at baseline. Patient-centered outcomes, including pain severity (primary outcome), pain interference, depression, anxiety, PTSD symptoms, sleep disturbance, fatigue, and treatment satisfaction, were collected at baseline, posttreatment, and at three-month follow-up. Two-sample t-tests were used to assess group differences on change scores for each outcome. Effect sizes were calculated using the following formula: (posttreatment mean – baseline mean)/baseline SD. Results To date, 48 patients were enrolled, and 35 patients completed baseline and posttreatment assessments. No differences between treatment conditions were found on any demographic or clinical variable at baseline. Patient drop-out rates were relatively low and comparable in each treatment condition. Similarly, no differences were found between treatment conditions in patient attendance or treatment satisfaction. However, a non-significant trend toward more improvement in the primary outcome of pain severity was found which favored EAET over CBT (t=1.868, p=0.07). Several patients in the EAET condition (N=3, 18%) had large improvements in pain severity, greater than -3 on an 11-point (0-10) scale, whereas no patient in the CBT condition had such large improvements. Overall, EAET delivered a moderate effect size of -0.60 for pain severity, whereas CBT had a small effect size of -0.22. Improvements in secondary outcomes (pain interference, depression, anxiety, sleep disturbance, fatigue, and PTSD symptoms) were generally small and did not differ between groups. Conclusions EAET appears to be a reasonable, and potentially more efficacious, alternative to CBT for older veterans with chronic musculoskeletal pain. Additional groups are planned for this pilot, and 3-month follow-up data are currently being analyzed. In addition, a larger RCT using therapists who are not involved in the research design and methods is planned. Further research is also needed to elucidate the distinct and similar mechanisms of action for each treatment approach and to assess baseline predictors of treatment response, especially given the large improvements among some patients in the EAET condition. This research was funded by This research was supported with a Beginning Scholar Pilot Grant from the American Psychoanalytic Association.