Strategies to Assist With Management of Pain (STAMP)

A Comparative Effectiveness Randomized Controlled Trial of Mindfulness Meditation Versus Cognitive Behavioral Therapy for Opioid-Treated Chronic Low Back Pain

Chronic low back pain (CLBP) has no known effective treatment. While often treated with long-term opioid therapy, opioids do not work well for many patients and can cause serious side effects, including addiction, poorer mental health, and overdose death. Even when paired with a standard-of-care cognitive behavioral therapy (CBT), results are limited. Patients, families and clinicians are very interested in using alternative treatments for CLBP, especially complementary and integrative treatments such as mindfulness meditation (MM). MM helps train the mind to bring non-judgmental and accepting attention to present-moment experiences such as pain. MM offers an active and safe self-care approach to chronic pain that contrasts with the passive and potentially harmful nature of opioid treatment, and may prove more effective than CBT in helping improve health and well-being, and reduce reliance on opioids in adults with opioid-treated CLBP. Although this hypothesis is supported by early research, including a pilot study by the Principal Investigator, evidence on MM's effectiveness in this population is inconclusive, presenting a critical knowledge gap.

With input from patients, family members, and clinicians, the Investigators have designed a study to address this gap and propose a clinical trial that will compare the effectiveness of MM to standard-of-care CBT in opioid-treated CLBP. Based on the existing research, it is hypothesized that MM training will lead to a larger reduction in pain intensity, increase in physical function, improvement in quality of life, and decrease in daily opioid dose, as compared to CBT training, with benefits of MM especially notable in adults with worse mood, anxiety or unhealthy opioid-use behaviors who often experience more severe symptoms of CLBP and less improvement in response to existing therapies.

To test these hypotheses, 766 adults with opioid-treated CLBP will be randomly assigned into one of two 8-week treatment groups: MM (383 participants) that will receive the MM training or CBT (383 participants) that will receive the CBT training. Due to the COVID-19 pandemic-related restrictions, the study protocol was modified in October 2020 so that the study can be completed virtually.

The effectiveness of MM versus CBT will be assessed over a 12-month period with patient-reported measures, recommended by experts and endorsed by our stakeholder partners, including patients with opioid-treated CLBP, their families and clinicians.

Study Overview

• Status: Completed
• Conditions: Chronic Low Back Pain
• Intervention / Treatment: Behavioral: Mindfulness Meditation; Behavioral: Cognitive Behavioral Therapy

Detailed Description

Chronic low back pain (CLBP) is the most common disabling chronic noncancer pain condition treated with opioids. Many opioid-treated patients experience inadequate pain relief and disability as well as dose-dependent adverse effects of opioids, such as worse mental health, opioid misuse, overdose and death. They frequently have co-occurring depression, anxiety, and opioid use disorders, which worsen outcomes. Poor outcomes and opioid-related harms underscore the need for safe and effective strategies for chronic pain care and opioid dose reduction, especially in high-impact, opioid-treated pain, as noted by the Institute of Medicine, the National Institutes of Health, and the Patient-Centered Outcomes Research Institute.

The investigators pilot randomized controlled trial (RCT) of mindfulness meditation (MM), a popular mind-body modality, demonstrated its potential to safely improve the health of patients and reduce opioid dosage in opioid-treated CLBP. To expand the evidence for MM for use in opioid-treated chronic pain, the investigators propose a 5-year multi-site, mixed-methods pragmatic RCT comparing the effectiveness of MM to standard-of-care cognitive behavioral therapy (CBT) for improving outcomes in opioid-treated CLBP. The study team will follow 766 participants over 12 months and compare outcomes that matter to patients and their families in 383 adults randomized to the MM group to 383 adults randomized to the CBT group, controlling for relevant factors.

The specific aims of this study are:

1. To compare the effectiveness of MM to CBT for reducing pain and increasing function. Current study is based on hypothesis that adults with opioid-treated CLBP in the MM group will report a greater reduction in pain severity and a greater increase in function at 6 and 12 months compared to those in the CBT group.
2. To compare the effectiveness of MM to CBT for improving quality of life (QoL) and reducing daily opioid dose. Study team hypothesize that adults with opioid-treated CLBP in the MM group will report a greater improvement in QoL and a greater decrease in daily opioid dose at 6 and 12 months compared to those in the CBT group.
3. To examine if participant baseline characteristics impact treatment response to MM or CBT. Study team hypothesize that among those with increased baseline symptom severity of anxiety, depression and opioid misuse behaviors, MM will be more beneficial than CBT for improving Aim 1 and Aim 2 outcomes.

Both MM and CBT interventions are patterned after established programs, adapted to meet the needs of patients with opioid-treated CLBP, with input from content experts and patient partners. The manualized interventions are delivered by trained therapists over 8 weeks in weekly two-hour group sessions in addition to care the participants are already receiving from their regular clinicians; during the COVID-19 pandemic, the interventions are delivered virtually. Participants are also be asked to practice MM or CBT strategies at home during the entire study (at least 30 minutes/day, 6 days/week).

Eligibility criteria will focus on English-speaking adults ≥21 years old, with moderate-to-severe CLBP treated with ≥15 mg/day of morphine-equivalent opioid dose for ≥3 months. The study will implement a limited set of exclusionary criteria to ensure a diverse sample, from which findings can be generalized.

Outcome measures were selected and prioritized based on guidelines and stakeholder input. They are collected at baseline, at 3, 6, 9 and 12 months. Only baseline and 12 months post-entry data collection is conducted in person; the 3, 6, and 9-month data collection occurs online or by phone to minimize burden. Due the COVID-19 pandemic, the study protocol was modified to allow for the completion of all assessments and data collection virtually.

Pain severity and function, as assessed by standard, validated survey measures, will serve as primary (Aim 1), and quality of life and opioid dose (morphine-equivalent mg/day) as secondary (Aim 2) outcomes. Severity of negative affect (depression, anxiety) and opioid misuse behaviors, also measured by validated surveys, are the main hypothesized predictors of treatment success (Aim 3). The repeated measures intention-to-treat outcome analysis will compare the change in primary and secondary outcomes over the 12 month period and across the two groups. To determine prognostic factors of treatment effect, a linear mixed model analysis will be performed for Aim 1 and Aim 2 outcomes, adjusting for potential confounders, study site and a random intercept for subject.

A team of experienced investigators and engaged stakeholders will carry out this multi-health system, multi-site study led by the faculty from the University of Wisconsin (Madison, WI), Harvard Medical School (Boston, MA) and the University of Utah (Salt Lake City, UT). Stakeholders helped develop this proposal and will be integrally involved as partners in all aspects of the study, from finalizing the methods, trouble-shooting implementation of the research plan, and dissemination of results.

Positive findings of this study could help improve health outcomes and reduce daily opioid dose in patients with opioid-treated CLBP, and inform clinical decisions of patients and clinicians about the choice between MM and CBT for opioid-treated CLBP.

*The Results Reporting due date has been extended per PCORI to be 9/30/2023.

• Study Type: Interventional
• Enrollment (Actual): 770
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Brigham and Women's Hospital
  • Pennsylvania
    • Hershey, Pennsylvania, United States, 16802
      • Pennsylvania State University
  • Utah
    • Salt Lake City, Utah, United States, 84112
      • University of Utah
  • Wisconsin
    • Madison, Wisconsin, United States, 53715
      • University of Wisconsin-Madison

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 21 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria (per self-report): English-speaking; age ≥ 21 years old; chronic low back pain (defined as a pain in lumbosacral region or sciatica for ≥3 months), with an average daily back pain score ≥3 on a 0-10 numerical rating scale (question from the Brief Pain Inventory), treated with ≥30 mg/day of morphine-equivalent dose for ≥3 months; at least moderate CLBP-related disability (≥21 score on the Oswestry Disability Index); capable of giving informed consent; willing to complete the study activities.

Exclusion Criteria (per self-report): prior formal Mindfulness Meditation or Cognitive Behavioral Therapy training; current pregnancy; diagnosis of borderline personality, delusional, or bipolar (mania) disorder; inability to safely or reliably participate in the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Mindfulness Meditation; Mindfulness Meditation intervention, adjunctive to usual care for opioid-treated chronic low back pain.	Behavioral: Mindfulness Meditation; The Mindfulness Meditation intervention will teach participants the mindfulness meditation-based strategies, tailored to the needs of those with opioid-treated chronic lower back pain. It consists of eight weekly 2-hour group sessions guided by trained therapists. In addition to session attendance, participants are asked to practice at home at least 6 days/week, 30 minutes/day during the study. In addition to the intervention, the participants will receive usual care for opioid-treated CLBP through their regular clinicians, per their recommendations.; Other Names: Mindfulness; Meditation
Active Comparator: Cognitive Behavioral Therapy; Cognitive Behavioral Therapy intervention, adjunctive to usual care for opioid-treated chronic low back pain.	Behavioral: Cognitive Behavioral Therapy; The Cognitive Behavioral Therapy (CBT) intervention will teach participants the CBT-based strategies, tailored to the needs of those with opioid-treated chronic lower back pain. It consists of eight weekly 2-hour group sessions guided by trained therapists. In addition to session attendance, participants are asked to practice at home at least 6 days/week, 30 minutes/day during the study. In addition to the intervention, the participants will receive usual care for opioid-treated CLBP through their regular clinicians, per their recommendations.; Other Names: CBT

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Intensity	4 pain severity items from the Brief Pain Inventory	Baseline to 12 months
Physical Function	10-item Oswestry Disability Index	Baseline to 12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quality of Life	12-item Short Form-12	Baseline to 12 months
Daily Opioid Dose	Timeline Followback Method (morphine-equivalent dose [mg/day] over the prior 14 days)	Baseline to 12 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Depression Symptom Severity	14-item Hospital Anxiety and Depression Scale	Baseline to 12 months
Anxiety Symptom Severity	14-item Hospital Anxiety and Depression Scale	Baseline to 12 months
Opioid Use Behaviors	17-item Current Opioid Misuse Measure	Baseline to 12 months
Opioid Medication Compliance	8-item Opioid Compliance Checklist	Baseline to 12 months

Collaborators and Investigators

• Sponsor: University of Wisconsin, Madison
• Collaborators: Patient-Centered Outcomes Research Institute
• Investigators: Principal Investigator: Aleksandra E Zgierska, MD PhD, Penn State University; Principal Investigator: Bruce P Barrett, MD PhD, University of Wisconsin, Madison

Publications and helpful links

General Publications

• Zgierska AE, Burzinski CA, Garland EL, Lennon RP, Jamison R, Nakamura Y, Barrett B, Sehgal N, Mirgain SA, Singles JM, Cowan P, Woods D, Edwards RR. Mindfulness-based therapy compared to cognitive behavioral therapy for opioid-treated chronic low back pain: Protocol for a pragmatic randomized controlled trial. Contemp Clin Trials. 2021 Nov;110:106548. doi: 10.1016/j.cct.2021.106548. Epub 2021 Sep 1.

Helpful Links

• Strategies To Assist with Management of Pain (STAMP) Study Website

Study record dates

Study Major Dates

• Study Start (Actual): June 30, 2017
• Primary Completion (Actual): January 15, 2023
• Study Completion (Actual): January 15, 2023

Study Registration Dates

• First Submitted: April 11, 2017
• First Submitted That Met QC Criteria: April 11, 2017
• First Posted (Actual): April 14, 2017

Study Record Updates

• Last Update Posted (Estimated): June 16, 2023
• Last Update Submitted That Met QC Criteria: June 13, 2023
• Last Verified: June 1, 2023

More Information

Terms related to this study

• Keywords: Chronic Pain; Chronic Low Back Pain; Cognitive Behavioral Therapy; CLBP; Mindfulness Meditation; Opioid Therapy; Opioid-treated Chronic Low Back Pain
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Back Pain; Low Back Pain
• Other Study ID Numbers: 2017-0353; A532007 (Other Identifier: UW Madison); SMPH/FAMILY MED/FAMILY MED (Other Identifier: UW, Madison); Protocol_V20-00, 03.07.2022 (Other Identifier: HS-IRB UW, Madison)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Data dictionaries, programming codes, qualitative codebooks, and other study materials will be provided to the funding agency, Patient-Centered Research Outcomes Institute (PCORI) after the study completion in order to promote replication of the research process. A final, clean dataset will be available for data sharing after the project and analysis completion. PCORI may share these materials and data upon request, after consultation with the PI.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No