Predictors of patient treatment adherence and moderators of response for a randomized clinical trial comparing remote cognitive behavioral therapy approaches for high-impact chronic musculoskeletal pain

ABSTRACT: Remote cognitive behavioral therapy-based interventions for chronic pain (CBT-CP-based) have consistently shown modest pain benefits. With remote treatment availability accelerating and increasingly tight healthcare resources, clinical decision-makers need to understand when working with a therapist may be beneficial vs a largely self-directed online program. Using data from a large-scale 3-arm pragmatic trial, we assessed the role of patient session adherence and potential moderators of intervention pain severity effectiveness for 2 remote CBT-CP-based approaches (online program [painTRAINER] and therapist-delivered telephone or video program [health coach]) and usual medical care. Of the prespecified moderators (demographics [sex, age, race/ethnicity, rurality], social determinants of health, and clinical variables [comorbid depression and/or anxiety, multiple types of chronic pain]), the health coach program was more effective than painTRAINER at 3 months among men and for those who screened positive for depression. No other factors moderated intervention pain severity effects at 3 or 12 months. The health coach program had higher session adherence than painTRAINER (70.4% vs 47.8%). Among intervention completers, pain severity outcomes were similar between CBT-CP-based interventions (Adjusted relative risk [95% confidence interval]: 0.99 [0.85-1.16] and 0.93 [0.82-1.05] at 3 and 12 months, respectively), suggesting that both interventions may be helpful for those with a variety of demographic and clinical characteristics if adherence is achieved. Participant engagement is critical in optimizing outcomes for online programs, but these findings suggest flexibility in the specific modality for delivering remote CBT-CP based on patient preference and healthcare system capacity that may enhance scalability and patient access to care.