Behavioral Intervention Reduces Chronic Pain in people with dialysis-dependent kidney failure: JAMA

A randomized clinical trial has found that cognitive behavioral intervention may alleviate chronic pain in individuals with kidney failure undergoing maintenance hemodialysis.

The clinical trial found that training people on how to manage pain reduced the extent to which pain affected their work and social activities, mood, and relationships. The pain coping skills training, which was adapted for people undergoing long-term dialysis, also improved other effects of pain, including the intensity of pain, depression, anxiety, and quality of life. Pain coping skills training is an approach widely used for chronic pain, but it had not previously been tested for people treated with dialysis.

“Very few interventions have been shown to improve the quality of life for people with end-stage kidney disease being treated with dialysis,” said Dr. Paul Kimmel, program director at NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), which led the study. “For example, opioids, which have been a main treatment for pain in this population, have side effects that can be more pronounced in the presence of kidney failure, making pain management challenging.”

More than 808,000 people in the United States are living with end-stage kidney disease, and 68% of them receive treatment with dialysis. People with dialysis-dependent kidney disease often experience chronic pain yet have limited pain treatment options. Furthermore, sticking to pain treatment plans can be difficult while undergoing dialysis. The study research group, known as the Hemodialysis Opioid Prescription Effort (HOPE) consortium, thus aimed to develop a behavioral intervention that would decrease the perception of pain, improve quality of life, and reduce opioid use among hemodialysis populations. This study is the largest randomized controlled trial to show that a nonpharmacologic pain intervention provides benefits to people with end-stage kidney disease being treated with dialysis.

The multi-center trial enrolled 643 adults being treated with maintenance dialysis for end-stage kidney disease and experiencing chronic pain. About half of participants were assigned to the pain coping skills training intervention, while the other half received usual clinical care with no trial-based intervention. The pain coping skills training comprised 12 weeks of virtual, one-on-one, coach-led sessions to teach coping skills for chronic pain, enhance self-efficacy (the belief in one’s ability to achieve goals), and reduce pain-related sleep difficulties, anxiety, and stress. The intervention included instruction, modeling of skills, guided practice, and experiential training. The coach-led sessions were followed by 12 weeks of automated interactive voice response sessions to refresh the newly acquired skills.

At 12 weeks, 51% of people in the pain coping skills training group reported a reduction in pain interference vs. 37% in the usual care group, and the benefit continued throughout the 24-week intervention period. The difference between the two groups diminished at week 36, 12 weeks after the intervention ended. Researchers believe people receiving pain coping skills training may need continued reinforcement to see additional or long-term benefit. The pain coping skills training also improved pain-related outcomes of pain severity, depression, anxiety, quality of life, and pain catastrophizing (a negative mental and emotional response to anticipated or actual pain that is associated with poor pain outcomes).

The study results indicate that pain coping skills training may be an appealing alternative or complement to pain medications. Although the effect of the pain coping skills training on the overall cohort was modest, its high acceptability, tolerability, and safety and its observed benefits to pain, anxiety, depression, and quality of life support further research on developing nonpharmacologic, non-invasive strategies for managing pain in dialysis populations.

“Future work will focus on how to prolong the favorable effects of pain coping skills training and how to broadly implement this intervention in clinical practice,” said lead author Dr. Laura M. Dember, nephrologist and clinical investigator at the University of Pennsylvania Perelman School of Medicine, Philadelphia. “Based on the successful results of this study, our hope is that this intervention can be made available broadly to patients receiving dialysis.”