Chronic Pain Care Has Evolved. Access Has Not. A New NIH-Funded Study Suggests a Smartphone App May Help Change That.
Peer-reviewed research published in JMIR Human Factors finds that adults living with chronic pain engaged with a digital behavioral health program.
KIRKLAND, WA, June 10, 2026 — Chronic pain care has evolved, but access remains a serious problem. Behavioral and nonpharmacologic approaches are increasingly recommended as first-line treatments, yet meaningful support is still out of reach for millions of patients. A new National Institutes of Health (NIH)-funded, peer-reviewed study evaluating Salty for Chronic Pain, a digital behavioral health program created by 2Morrow and conducted in collaboration with family medicine researchers at the University of Washington School of Medicine addresses an important question at the heart of that tension: will people actually engage with a digital behavioral health program designed to meet them outside the clinic?
The answer, it turns out, is yes, and in ways that surprised even the researchers.
In a field where app abandonment is the norm, patients in this feasibility trial did not just download the program and move on. They kept coming back. On average, participants used the Salty for Chronic Pain app on 27 unique days over a 12-week period, worked through more than 25 structured lessons rooted in evidence-based behavioral science, and did so entirely without automated reminders, after a technical issue prevented push notifications from being sent at any point during the study.
The absence of reminders was unplanned. The engagement was not.
"We know behavioral approaches can be effective and meaningful for chronic pain, but most people never get access to them," said Jo Masterson, RN, CEO of 2Morrow and the study's principal investigator. "What this study shows is that when you put evidence-based tools directly in the hands of people living with pain, in a format that fits their life, you can expand the reach of those behavioral strategies. And when you do, people use them and find them valuable."
The Problem Is Not the Science. It Is the Gap Between the Science and Real Life.
More than 50 million Americans live with chronic pain. Approximately 8.5% experience pain severe enough to limit their ability to work, maintain relationships, and participate in daily life. The condition costs the U.S. economy between $560 and $635 billion annually.
The treatments with the strongest long-term evidence are not medications alone. National guidelines now recommend behavioral interventions, including Acceptance and Commitment Therapy (ACT), cognitive behavioral therapy, and mindfulness, as first-line or complementary approaches for chronic pain. The evidence behind these approaches is strong and well established.
But here is the reality most patients face. Specialists are scarce. Wait times are long. Insurance coverage is inconsistent. Primary care providers, who are often the only clinician a pain patient ever sees, have limited training in behavioral approaches, limited time in each visit, and limited options to offer beyond medication. The National Academy of Medicine has called for innovative strategies to reduce these barriers and support more equitable pain care.
That is the gap. And that is what this study was designed to address.
What the Study Found
The study enrolled adult primary care patients with chronic pain across four health systems and 60 clinics in Washington and Idaho. Participants were randomized to receive access to the 12-week Salty for Chronic Pain program, a structured digital behavioral health intervention that addresses the physical, emotional, and social dimensions of living with pain, with all content grounded in ACT principles.
Among the 40 participants who activated the app, the findings were striking:
81.6% of patients given access to the app downloaded it and set up their account with no help, tech support, or training
During the 12-week program, participants used the app for an average of 27 unique days, with some continuing to engage for up to 118 days
1 in 4 participants completed all of the program's core content, working through all 58 structured lessons across all 4 content areas
82.5% actively used the app's tools to track and better understand their own pain
86.7% said the app helped them better understand or manage their pain
90% said they would recommend it to others
Every one of these outcomes occurred without a single automated reminder
"One of the most striking things we found was that patients kept coming back to the app entirely on their own. We did not send a single automated reminder during the study," said Deanna Waters, LMHC, Vice President of Participant Success at 2Morrow and a co-investigator on the study. "That kind of self-motivated engagement tells us something important about what people living with chronic pain are genuinely looking for."
The findings are notable not simply because participants opened the app, but because they progressed through structured, sequential content without external prompting. This level of self-directed engagement reflects both the design of the program and the significant unmet need for accessible, evidence-based chronic pain support.
This Is Not Another Wellness App
That distinction matters and the researchers are deliberate about making it.
Published reviews of pain-related apps on the market have found that many lack credible content, clinical input, or meaningful functionality, and fail to engage users over time. Salty was built to be different, and the record shows it.
The program was developed with direct input from patients, clinicians, and pain behavioral health specialists during an earlier phase of the research. Clinicians who participated in that design phase were explicit: they wanted evidence-based options for their patients that did not require significant clinical time to deliver. The result is a program that extends behavioral support beyond the clinic visit without placing additional burden on clinical staff.
The content itself is built on Acceptance and Commitment Therapy, one of the most rigorously studied behavioral frameworks for chronic pain management. The program guides users through 58 structured lessons across four domains covering the physical, emotional, social, and values-based dimensions of living with pain, with tools for daily tracking, self-reflection, personalized insights, and optional coaching. There is also a library of additional on-demand content for those who wish to dive deeper.
The research behind it carries full academic and institutional weight:
Funded by the NIH Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative®, and administered by the National Center for Complementary and Integrative Health (NCCIH), part of the NIH, under award R44AT011593
Conducted as a formal NIH Small Business Innovation Research collaboration, with 2Morrow serving as grant recipient and developer and the University of Washington Department of Family Medicine serving as the academic research partner
Now peer-reviewed and published in JMIR Human Factors, one of the leading journals in digital health research
Where Things Stand Now
The Salty for Chronic Pain program is currently being piloted at clinics and health systems across the United States as 2Morrow moves toward broader availability. The goal is straightforward: give primary care providers a credible, scalable, evidence-based option they can offer patients at the point of care, one that meets people where they are and works without demanding more from already stretched clinical teams.
The authors are clear about what this study is and what it is not. It was a feasibility trial with a relatively small sample size. Larger studies are needed to evaluate the full impact on pain outcomes, functioning, and quality of life. Future research will explore which patients are most likely to benefit, whether flexible lesson sequencing or the reintroduction of automated reminders could further increase engagement, and what dose of content is most strongly linked to clinical benefit.
What this study establishes, clearly and with peer-reviewed evidence, is that when support is made more reachable and more realistic for everyday life, people living with chronic pain will engage with it consistently, and on their own terms.
For the 50 million Americans living with chronic pain, that is not a small finding.
It is the beginning of something.
About 2Morrow
2Morrow is a Kirkland, Washington-based digital health company that creates evidence-based digital health and digital therapeutic programs to improve health and well-being based on behavioral science. Trusted by some of the nation's largest employers, states, and health plans, 2Morrow has empowered over a million individuals on their journey to improved health. The Salty for Chronic Pain program is currently being piloted with clinics and health systems. For more information, visit www.2morrowinc.com or learn more about the Salty program at www.2morrowinc.com/salty-for-pain.
About the Study
"Participant Engagement With a Digital Behavioral Health App for Chronic Pain: Descriptive Secondary Analysis of a Feasibility Randomized Controlled Trial" was authored by Susan M. Zbikowski, PhD; Jo Masterson, RN; Yohali Burrola-Mendez, PhD; Chialing Hsu, MS; Kris Pui Kwan Ma, PhD; Ying Zhang, MD; Deanna Waters, LMHC; and Kari A. Stephens, PhD.
The study was published in JMIR Human Factors (2026;13:e88122).
URL: https://humanfactors.jmir.org/2026/1/e88122
DOI: 10.2196/88122
The research was funded by the NIH Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative®, and administered by the NIH’s NCCIH under award R44AT011593. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Media Contact:
Deanna Waters
Vice President of Participant Success
2Morrow Inc
Study link: https://humanfactors.jmir.org/2026/1/e88122