A cognitive behavioral intervention known as pain coping skills training (PCST) has shown promise in alleviating chronic pain among individuals with kidney failure undergoing maintenance hemodialysis. The randomized clinical trial revealed that PCST reduced the interference of pain on daily activities compared to usual care.
Impact on Pain Interference
After 12 weeks of PCST, participants experienced a significant reduction in pain interference, with a between-group difference of -0.49 points on the Brief Pain Inventory (BPI) scale (95% CI -0.85 to -0.12, P=0.009). This positive effect persisted through week 24 (between-group difference -0.48, 95% CI -0.86 to -0.11). However, by week 36, the difference in pain interference scores was no longer significant compared to usual care (between-group difference -0.34, 95% CI -0.72 to 0.04).
According to Laura Dember, MD, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, the intervention produced a clinically important change for a substantial proportion of participants. While the overall cohort effect was modest, a greater proportion of participants in the intervention group experienced a reduction of over 1 point in the BPI Interference score, with an absolute difference of 14% and a relative difference of 39% (number needed to treat of seven).
Secondary Outcomes and Quality of Life
Dialysis patients who participated in PCST also showed greater improvements in several secondary outcomes by week 24, including:
- Pain intensity (between-group mean difference of -0.50 points on the BPI Severity scale)
- Catastrophizing (a -1.49-point difference on the Pain Catastrophizing Scale)
- Depression (a difference of -0.94 points on the Patient Health Questionnaire)
- Anxiety (a -0.98-point difference on the Generalized Anxiety Disorder scale)
The PCST group also experienced greater improvements on the single-item quality of life scale, although the between-group difference did not reach statistical significance.
Study Details and Patient Population
The HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis randomized 643 participants, with 319 receiving PCST and 324 receiving usual care. The study took place across 16 U.S. academic centers and 103 outpatient dialysis facilities between January 2021 and April 2023. The average age of participants was 60.3 years, with 44.8% being female, 47.9% Black, 18.5% Hispanic or Latino, and 32.7% white. All participants had been undergoing in-center maintenance hemodialysis for at least 90 days and reported moderate to severe chronic pain.
Intervention Protocol
The PCST involved weekly coach-led sessions lasting 45 to 50 minutes via video or telephone conferencing for 12 weeks, followed by 12 weeks of automated interactive voice response sessions. The program content was adapted to include modules addressing pain-related anxiety, stress, and sleep difficulties.
Expert Commentary
Paul Kimmel, MD, of the National Institute of Diabetes and Digestive and Kidney Diseases, emphasized the significance of the findings, stating, "Very few interventions have been shown to improve the quality of life for people with end-stage kidney disease being treated with dialysis." He also noted the challenges of pain management in this population due to the side effects of opioids, a common treatment, being more pronounced in the presence of kidney failure.
Dember and colleagues highlighted the acceptability, tolerability, and safety of cognitive behavioral therapy, making the results "particularly compelling." They also noted the appeal of nonpharmacologic approaches given the high medication burden in this patient population and the absence of adverse effects attributable to PCST.
Future Directions
Researchers plan to focus on prolonging the favorable effects of pain coping skills training and implementing this intervention broadly in clinical practice. Dember expressed hope that the intervention can be made available to a wider range of patients receiving dialysis.
