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A new study published in the Annals of Family Medicine looked at whether peer-delivered cognitive behavioral training could improve functioning in patients with diabetes.

“We wanted to test an intervention that did not rely on opioids to relieve pain, improve functioning, and increase exercise in people with diabetes and chronic joint pain,” study author Dr. Monika Safford told us. “This is a very common combination that affects up to 70 per cent of people with diabetes. We also hoped that diabetes parameters like blood glucose, blood pressure, and cholesterol would also improve as a result of increased physical activity.”

Researchers based the intervention on a large body of evidence for cognitive behavioral approaches to behavior change. Cognitive behavior therapy, or CBT, has been shown to work in a variety of chronic pain conditions and in depression, which often accompanies chronic pain.

“The problem in the U.S. is that this kind of therapy is delivered by psychologists, and there are very few of those to go around,” Safford told us, “especially in remote locations like the region in which we conducted the study – the rural south that includes largely African American communities, a region known as the black belt of the U.S.”

Diabetes self-management interventions had been done in this region by the researchers, with the interventions delivered by trained peer coaches. In the course of doing their first trial, their coaches kept telling them that their clients were in too much pain to exercise.

“I realized that we had not included anything in the intervention specifically designed to overcome pain as a barrier to exercise,” Safford told us. “In looking further in the literature, I found remarkably little on the topic of chronic joint pain in diabetes. With the opioid epidemic continuing to rage, we definitely saw this as a shortcoming – finding effective, widely scalable interventions that did not rely on opioids or mental health professionals.”
 
To test out their theory, researchers conducted a cluster, randomized trial, the most rigorous design to answer an experimental question. The hypothesis was that the living healthy intervention would reduce pain, increase functioning, and increase exercise in the intervention participants, compared to an ‘intention control’.

“This type of control is important in studies of cognitive behavior interventions, since talking to a nice person on the phone ten times can improve quality of life without any cognitive behavior intervention,” Safford told us. “Our ‘intention control’ was a series of phone calls about general health topics, also delivered by peer coaches. This design allowed us to attribute any benefits observed in the intervention participants to the cognitive behavior intervention.”

Results of the study showed that the living healthy intervention reduced pain, improved functioning, and increased exercise. It did not change diabetes parameters (blood glucose as reflected in ‘hemoglobin a1c’, blood pressure, and cholesterol).

The researchers were surprised with the results.

“We did not expect such a dramatic effect on pain, functioning, and improvements in exercise,” Safford told us. “This came at a point in the trial that was earlier than expected.”

The initial study plan included 400 subjects, but it became clear that the answers were obtained after just 200 patients. Safford believes this is an exciting intervention because it does not rely on opioids to reduce pain, it integrates diabetes self-care with pain management.

“People really like the intervention,” Safford told us. “We had over 85 per cent retention in the intervention arm and nearly all participants completed the intervention which is quite remarkable, really.”

The next challenge is how to implement this widely as few health systems or doctor’s offices are set up to deliver this kind of intervention.

“I would very much like to explore how to scale this effective intervention up nationally,” Safford told us, “to make it available to the many people living with diabetes and chronic pain in the U.S.”