Human Studies

Differences among patients can moderate the impact of evidence-based treatments (i.e., heterogeneity of treatment effects), leading patients to get more or less benefit. The Learning About My Pain (LAMP) study was a randomized comparative effectiveness trial of 10-week literacy-adapted group cognitive-behavioral therapy for chronic pain (CBT) vs. pain psychoeducation groups (EDU) vs. usual medical care (UC). We examined potential sociodemographic and cognitive moderators of treatment effect among participants with post-treatment assessments (N = 241). Analyses were conducted using moderation in the PROCESS macro in SPSS and significant interactions were explored further. Education and primary literacy moderated the difference between CBT and EDU on pain intensity; primary literacy, health literacy, and working memory moderated the difference between CBT and EDU on pain interference. Analyses revealed few significant moderation effects relative to UC. No moderators were identified for depression. Neither sex nor minority status moderated any differences between groups. Patients with lower education, literacy, and working memory gained more benefit from CBT than EDU. When provided sufficient guidance and structure in a way that is meaningfully adapted, highly disadvantaged patients achieved as much benefit as less disadvantaged patients, suggesting that the literacy-adapted CBT more successfully met the needs of this population. Trial registration: clinicaltrials.gov identifier NCT01967342 Perspective: This article presents findings related to heterogeneity of treatment effects for simplified group psychosocial treatments for chronic pain. The results suggest that educationally, cognitively, or literacy-disadvantaged patients benefit most from the more structured approach of literacy-adapted cognitive-behavioral therapy rather than psychoeducation, whereas less disadvantaged patients benefit from either treatment.

Adverse childhood experiences (ACEs; e.g., parental divorce, physical or sexual abuse) are more prevalent in individuals with chronic pain compared to the general population. Both increased maternal ACEs and chronic pain have been associated with poor physical and emotional functioning in offspring. However, the mechanisms driving these associations are poorly understood. Thus, this cross-sectional study evaluated the relation between maternal ACEs, mothers' current functioning, and children's physical and emotional functioning in a sample of mothers with chronic pain and their 8-12 year-old children. Results indicated a higher prevalence of at least 1 ACE in this sample of mothers with chronic pain (84%) compared to normative data from a community sample of women. Higher maternal ACE scores corresponded with lower physical and social functioning, greater anxiety and depressive symptoms, greater fatigue and sleep disturbances, and greater pain intensity and pain interference in mothers. Higher maternal ACE scores significantly correlated with higher child self-reported depressive symptoms, but not somatic symptoms or functional impairment. A path model indicated that maternal depressive symptoms accounted for the relation between higher maternal ACE scores and children's depressive symptoms. Intervening on maternal depression among mothers with chronic pain may reduce the impact of intergenerational ACE transmission. Perspective: This article presents evidence regarding the intergenerational impact of adverse childhood experiences in a large sample of mothers with chronic pain and their school-aged children. Maternal depressive symptoms accounted for the relation between maternal ACEs and children's depressive symptoms providing evidence regarding targets for preventive interventions.

We conducted a randomized controlled trial of an individually tailored, virtual perspective-taking intervention to reduce race and socioeconomic status (SES) disparities in providers' pain treatment decisions. Physician residents and fellows (n = 436) were recruited from across the United States for this two-part online study. Providers first completed a bias assessment task in which they made treatment decisions for virtual patients with chronic pain who varied by race (black/white) and SES (low/high). Providers who demonstrated a treatment bias were randomized to the intervention or control group. The intervention consisted of personalized feedback about their bias, real-time dynamic interactions with virtual patients, and videos depicting how pain impacts the patients' lives. Treatment bias was re-assessed 1 week later. Compared with the control group, providers who received the tailored intervention had 85% lower odds of demonstrating a treatment bias against black patients and 76% lower odds of demonstrating a treatment bias against low SES patients at follow-up. Providers who received the intervention for racial bias also showed increased compassion for patients compared with providers in the control condition. Group differences did not emerge for provider comfort in treating patients. Results suggest an online intervention that is tailored to providers according to their individual treatment biases, delivers feedback about these biases, and provides opportunities for increased contact with black and low SES patients, can produce substantial changes in providers' treatment decisions, resulting in more equitable pain care. Future studies should examine how these effects translate to real-world patient care and the optimal timing/dose of the intervention.