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BACKGROUND: Chronic pain is prevalent and costly; cost-effective non-pharmacological approaches that reduce pain and improve patient functioning are needed. OBJECTIVE: Report the incremental cost-effectiveness ratio (ICER),compared to usual care, of cognitive behavioral therapy (CBT) aimed at improving functioning and pain among patients with chronic pain on long-term opioid treatment. DESIGN: Economic evaluation conducted alongside a pragmatic cluster randomized trial SUBJECTS: Adults with chronic pain on long-term opioid treatment (N=814) INTERVENTION: A CBT intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorists, nurses) with additional support from physical therapists, and pharmacists. OUTCOME MEASURES: Cost per quality adjusted life year (QALY) gained, and cost per additional responder (≥ 30% improvement on standard scale assessment of Pain, Enjoyment, General Activity and Sleep). Costs were estimated as-delivered, and replication. RESULTS: Per patient intervention replication costs were $2,145 ($2,574 as-delivered). Those costs were completely offset by lower medical care costs; inclusive of the intervention, total medical care over follow-up was $1,841 lower for intervention patients. Intervention group patients also had greater QALY and responder gains than did controls. Supplemental analyses using pain-related medical care costs revealed incremental cost-effectiveness ratios (ICERs) of $35,000, and $53,000 per QALY (for replication, and as-delivered intervention costs, respectively); the ICER when excluding patients with outlier follow-up costs was $106,000 LIMITATIONS: Limited to one-year follow-up; identification of pain-related utilization potentially incomplete CONCLUSION: The intervention was the optimal choice at commonly accepted levels of willingness-to-pay for QALY gains; this finding was robust to sensitivity analyses.