PainRelief.com: What are the main findings?

Response: In our randomized clinical trial, we enrolled 770 adults with chronic low back pain (CLBP) who had moderate daily pain and functional impairment and had been taking at least 15 morphine milligram equivalents (MME) of opioids daily for at least three months. Participants were randomly assigned to either mindfulness-based therapy (MBT) or cognitive behavioral therapy (CBT), with both treatments adapted specifically for this population.

Each intervention consisted of eight weekly, 2-hour group sessions led by trained therapists, plus recommended at-home practice. Before the pandemic, the intervention sessions were delivered in person; since the pandemic – remotely. We followed participants for 12 months, assessing outcomes every three months.

Both the MBT and CBT groups significantly improved all primary outcomes—pain intensity, function, quality of life (mental and physical), and daily opioid use—compared to baseline, without adverse effects. Improvements began at 3 months and were sustained through 12 months, and importantly, MBT was found to be non-inferior to CBT for pain and functional outcomes, indicating that both approaches are safe and can be effective, viable options for opioid-treated CLBP.

PainRelief.com: What should readers take away from your report?

Response: It’s striking that our participants—many of whom had severe, long-standing back pain, high healthcare utilization, and were taking high-dose opioids (often ≥90 MME/day)—showed significant improvement across all main outcomes. Most had tried multiple treatments in the past with little success and entered the study with low expectations for meaningful relief. Clinically and in the literature, this population typically does not improve over time with standard care, and often worsens.

So, to see sustained improvements in pain, function, opioid use, and quality of life with therapies that are non-pharmacologic, low-risk, and also support mental health and coping was both encouraging and hopeful. These results suggest that we have effective, underused tools to help patients with even the most challenging CLBP.

While this JAMA Network Open article described findings stemming from validated questionnaires and numerical outcomes, our related publications include qualitative data showing that participants found the interventions useful and genuinely helpful. Taken together, these findings support the use of both mindfulness-based therapy (MBT) and CBT as effective options for patients with CLBP, including those with high-impact pain who require opioids.

One could reasonably ask: if these psychological therapies were offered earlier, might the need for long-term opioid therapy have been avoided altogether?

PainRelief.com: What recommendations do you have for future research as a result of this study?

Response: Our study showed that both MBT and CBT led to broad improvements in pain, function, quality of life, and opioid use. However, not everyone improved, and not all participants engaged fully with the treatment they were assigned. These therapies also remain largely inaccessible to many patients due to limited availability and insurance coverage; the therapy instruction length can also be a barrier.

Future research should focus on personalizing treatment—identifying which patients are more likely to benefit from MBT versus CBT. Patient preferences matter too: some may be drawn to mindfulness, for

example due to its growing popularity in wellness, while others may prefer the structure and familiarity of CBT, especially if they’ve encountered it in mental health care before.

We must also address barriers to access. Standard MBT and CBT programs are time-intensive and often delivered in person, which can be challenging for individuals with chronic pain and functional limitations. Our study, like others, found both in-person and remote formats can be effective. Giving patients options—telehealth or in-person—could significantly increase engagement and reach.

Additionally, we need to examine the long-term sustainability of these interventions: How long do the benefits last? Which components are most effective and commonly practiced? Answering these questions could help streamline the interventions—making them shorter, more targeted, and more appealing to patients without sacrificing effectiveness.

Lastly, improved access will require growing the behavioral health workforce and ensuring better insurance coverage for psychological treatments, just as we do for medications and physical therapy; subpar health plan coverage contributes to workforce shortages, reinforcing the gap in care for patients with chronic pain.

Disclosures: Please see those noted in the paper.

Citation:

Zgierska AE, Edwards RR, Barrett B, et al. Mindfulness vs Cognitive Behavioral Therapy for Chronic Low Back Pain Treated With Opioids: A Randomized Clinical Trial. JAMA Netw Open. 2025;8(4):e253204. doi:10.1001/jamanetworkopen.2025.3204

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Last Updated on April 15, 2025 by PainRelief.com