Development and pre-pilot testing of STAMP + CBT: an mHealth app combining pain cognitive behavioral therapy and opioid support for patients with advanced cancer and pain

Abstract

Purpose: We developed and piloted a mobile health app to deliver cognitive behavioral therapy for pain (pain-CBT), remote symptom monitoring, and pharmacologic support for patients with pain from advanced cancer.

Methods: Using an iterative process of patient review and feedback, we developed the STAMP + CBT app. The app delivers brief daily lessons from pain-CBT and pain psychoeducation, adapted for advanced cancer. Daily surveys assess physical symptoms, psychological symptoms, opioid utilization and relief. Just-in-time adaptive interventions generate tailored psychoeducation in response. We then conducted a single-arm pilot feasibility study at two cancer centers. Patients with advanced cancer and chronic pain used the app for 2 or 4 weeks, rated its acceptability and provided feedback in semi-structured interviews. Feasibility and acceptability were defined as ≥ 70% of participants completing ≥ 50% of daily surveys, and ≥ 80% of acceptability items rated ≥ 4/5.

Results: Fifteen participants (female = 9; mean age = 50.3) tested the app. We exceeded our feasibility and accessibility benchmarks: 73% of patients completed ≥ 50% of daily surveys; 87% of acceptability items were rated ≥ 4/5. Participants valued the app's brevity, clarity, and salience, and found education on stress and pain to be most helpful. The app helped participants learn pain management strategies and decrease maladaptive thoughts. However, participants disliked the notification structure (single prompt with one snooze), which led to missed content.

Conclusion: The STAMP + CBT app was an acceptable and feasible method to deliver psychological/behavioral treatment with pharmacologic support for cancer pain. The app is being refined and will be tested in a larger randomized pilot study. TRN: NCT05403801 (05/06/2022).

Keywords: Cognitive behavioral therapy; Just-in-time adaptive intervention; Oncology; Opioids; Pain management; mHealth.

Fig. 1

Diagram depicting app development procedures following the ORBIT Model for intervention development

Fig. 2

Screenshots of STAMP + CBT app intervention. From top left: app home screen, example pain survey EMA item, example negative thoughts survey EMA item, end of survey summary screen, and stoplight background colors for JITAI feedback and message examples (green, yellow, and red); second line—content examples: breathing relaxation, text with visuals, two 2D video screens, one of the 2D behavioral games, and the homepage for the resource library

Fig. 3

Flowchart summary of STAMP + CBT app features and functionalities, including pushed^a and patient-initiated content. EMA^b and JITAI^c survey components, and example “message bins”^d. ^aIf patients did not respond to or dismissed a push notification, they were not able to interact with that content. Content was delivered on a pre-determined schedule to mirror content delivery in pain-CBT modules, beginning with pain- and opioid-specific medical advice, biopsychosocial aspects of pain, stress and pain, goals and activity pacing, cognitive restructuring, emotional processing, and relaxation exercises. ^bUpon completion of EMAs, patients were shown a summary of their responses (see Fig. 2). On following screens, they could review individualized messages and advice, which were paired with links to pain-CBT content. ^cWhen patients reported severe symptoms, the app prompted them to contact their palliative care provider using the clinic phone number on the home screen or to call 911. The same algorithm also pushed an automated email that listed their severe symptoms to the study team. The study team then shared this report with the patient’s care team through secure email to encourage them to reach out accordingly. Patients were made aware that study staff monitored the app only during business hours. ^dEach “message bin” consisted of customized messages and paired educational content delivered on a rotating basis with a green, yellow, or red background corresponding to mild, moderate, or severe symptoms